Nursing Elites

1. To which of the following do the CDC Standard precautions recommendations apply?

• A. Patients with diagnosed infections only
• B. Blood or body fluids with visible blood only
• C. All body fluids including sweat
• D. All patients receiving care in hospitals

Correct answer: D

Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.

2. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

• A. Administer the feeding as ordered
• B. Pull the feeding tube out approximately 3 cm
• C. Flush the feeding tube with 60 cc of water
• D. Contact the physician

Correct answer: A

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

3. Following hospitalization for congestive heart failure, a client is discharged. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

• A. High Fowler's
• B. Supine
• C. Left lateral
• D. Low Fowler's

Correct answer: A

Rationale: The correct answer is High Fowler's. Sitting in a chair or resting in a bed in the high Fowler's position helps decrease the cardiac workload and facilitates breathing in clients with congestive heart failure. This position helps reduce venous return and increases lung expansion, improving oxygenation. The supine position (choice B) may lead to increased pressure on the heart and lungs, making it less suitable for these clients. The left lateral position (choice C) is not as effective as High Fowler's in reducing cardiac workload and improving breathing. Low Fowler's position (choice D) does not provide the same benefits as the High Fowler's position for clients with congestive heart failure.

4. When measuring a patient's body temperature, what factor should be considered that can influence the temperature?

• A. Constipation
• B. Diurnal cycle
• C. Nocturnal cycle
• D. Patient's emotional state

Correct answer: B

Rationale: When measuring body temperature, it is essential to consider factors that can influence it. The diurnal cycle, which refers to the body's natural temperature variations throughout a 24-hour period, can impact body temperature readings. Factors like exercise, age, and environment can also affect body temperature. Constipation does not directly influence body temperature. The 'nocturnal cycle' is not a recognized term in relation to body temperature. While a patient's emotional state can affect vital signs, it is not a primary factor in influencing body temperature measurements.

5. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

• A. Count the patient's respirations.
• B. Bilaterally percuss the thorax, noting any differences in percussion tones.
• C. Call for a chest x-ray and wait for the results before beginning an assessment.
• D. Inspect the thorax for any new masses and bleeding associated with respirations.

Correct answer: B

Rationale: In a situation where a patient is in significant respiratory distress, bilaterally percussing the thorax to note any differences in percussion tones is a crucial nursing intervention. Percussion provides instant feedback regarding changes in underlying tissue density, which can give important clues about the patient's physical status. This hands-on assessment technique is readily available and can be performed promptly. Counting the patient's respirations, while important, may not provide as much detailed information as percussion. Ordering a chest x-ray and waiting for the results can cause a delay in assessing and addressing the patient's immediate needs. Inspecting the thorax for new masses and bleeding, although relevant, may not offer as much real-time information about the patient's condition compared to percussion.

Similar Questions