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. 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.

3. If the child does not have ear problem, using IMCI, what should you as the nurse do?

• A. Check for ear discharge
• B. Check for tender swellings behind the ear
• C. Check for ear pain
• D. Go to the next question, check for malnutrition

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. In order to establish and maintain successful breastfeeding, which practice should a lactating mother try to follow?

• A. Initiate breastfeeding within 24 hours of birth
• B. Breastfeed on a schedule of every 2 to 3 hours
• C. Give a pacifier to an infant between feedings
• D. Find a breastfeeding support group to troubleshoot problems

Correct answer: D

Rationale: The correct answer is D. Finding a breastfeeding support group is crucial for a lactating mother to establish and maintain successful breastfeeding. This group can offer valuable advice, tips, and encouragement, helping the mother troubleshoot any issues that may arise during breastfeeding. Choices A, B, and C are incorrect because breastfeeding is a natural process that should not be overly scheduled, and giving a pacifier between feedings can interfere with establishing proper breastfeeding techniques.

5. A client scheduled for hysterosalpingography needs health teaching before the procedure. The nurse is correct in telling the patient that:

• A. She needs to void prior to the procedure
• B. A full bladder is needed prior to the procedure
• C. Painful sensation is felt as the needle is inserted
• D. Flushing sensation is felt as the dye in injected

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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