Nursing Elites

1. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

• A. Client lying on his back then flat on his abdomen on Trendelenburg position
• B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his
• C. Client lying flat on his back and then flat on his abdomen
• D. Client lying on his right then left side on Trendelenburg position

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

2. Which of the following foods should be avoided by patients experiencing xerostomia, except one? Which is the exception?

• A. Saltines
• B. Salsa
• C. Alcohol
• D. Dill pickles

Correct answer: D

Rationale: The correct answer is Dill pickles. Unlike the other choices, which can exacerbate xerostomia due to their dry or irritating nature, dill pickles, being tart and sour, can actually help stimulate saliva flow, which is beneficial for patients with xerostomia. Saltines, salsa, and alcohol are all known to contribute to dry mouth and should generally be avoided by individuals experiencing xerostomia.

3. Where should a nurse auscultate the apex beat?

• A. At the fifth intercostal space, along the midclavicular line
• B. At the mid-sternum
• C. 2 inches to the left of the lower end of the sternum
• D. 1 inch to the left of the xiphoid process

Correct answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

4. Before the nurse researcher starts her study, she analyzes how much time, money, materials and people she will need to complete the research project. This analysis prior to beginning the study is called:

• A. Validity
• B. Feasibility
• C. Reliability
• D. Researchability

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

5. A nurse is caring for a client who is to receive a mechanically altered diet. Which of the following client food choices necessitates intervention by the nurse?

• A. Scrambled eggs
• B. Cottage cheese
• C. Piece of wheat toast
• D. Sliced banana

Correct answer: D

Rationale: The correct answer is 'Sliced banana.' A mechanically altered diet is designed for clients who have difficulty chewing or swallowing. Sliced bananas, due to their texture and potential choking hazard for clients with swallowing difficulties, would necessitate intervention by the nurse. Scrambled eggs, cottage cheese, and a piece of wheat toast are softer and safer options for clients on a mechanically altered diet, making them appropriate choices.

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