Nursing Elites

1. What special consideration should be taken into account when Mario prepares Richard for postural drainage and percussion?

• A. Monitoring a respiratory rate of 16 to 20 per minute
• B. Assessing the client's ability to tolerate sitting and lying positions
• C. Ensuring the client is free of signs of infection
• D. Knowing the time of the client's last food and fluid intake

Correct answer: A

Rationale: The correct answer is A, 'Monitoring a respiratory rate of 16 to 20 per minute'. When performing postural drainage and percussion, it is crucial to monitor the respiratory rate to ensure the safety and effectiveness of the procedure. Choice B, 'Assessing the client's ability to tolerate sitting and lying positions', while important, is not directly related to the specifics of postural drainage and percussion. Similarly, option C, 'Ensuring the client is free of signs of infection', although important, is not directly linked to the procedure. Option D, 'Knowing the time of the client's last food and fluid intake', might be relevant for other procedures, but it is not the primary consideration for postural drainage and percussion.

2. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain:

• A. to rule out pneumothorax
• B. to rule out any possible perforation
• C. to decongest
• D. to rule out any foreign body

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.

3. What is the term for intestinal wounds associated with Crohn's disease that develop in different areas in the intestine, with normal tissue separating affected regions?

• A. Skip lesions
• B. Fistulas
• C. Fissures
• D. Loop ulcerations

Correct answer: A

Rationale: Skip lesions are typical characteristics of Crohn's disease, where patches of diseased intestine are interspersed with areas of healthy tissue. This is why option A is the correct answer. Option B, fistulas, are abnormal connections between two body parts, which is not what the question is describing. Option C, fissures, are small tears in the lining of the anus, which also do not fit the description in the question. Option D, loop ulcerations, is not a recognized medical term, making it an incorrect choice.

4. What is the most likely demonstration of cardiac cachexia?

• A. Decreased physical activity
• B. Weight loss and tissue wasting
• C. Poor urine output and tissue edema
• D. Cardiac arrhythmia and wet lung sounds

Correct answer: B

Rationale: Cardiac cachexia is a condition characterized by severe weight loss and tissue wasting. This typically occurs in patients suffering from heart failure due to an increased energy expenditure and reduced appetite, which is why choice B is the correct answer. The other choices are incorrect as they do not accurately describe the symptoms of cardiac cachexia. Decreased physical activity (choice A) can be a result of many conditions, not specifically cardiac cachexia. Poor urine output and tissue edema (choice C) are more indicative of kidney problems rather than cardiac cachexia. Finally, cardiac arrhythmia and wet lung sounds (choice D) are symptoms related to other cardiac conditions, not specifically to cardiac cachexia.

5. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase the chance of passing the stones, you instructed her to force fluids and do which of the following?

• A. Balanced diet C. Strain all urine
• B. Ambulate more D. Bed rest
• C.
• D.

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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