Nursing Elites

1. A test that can correctly identify those who do not have a given disease is:

• A. specific.
• B. sensitive.
• C. negative culture.
• D. marginal finding.

Correct answer: A

Rationale: The correct answer is 'specific.' A specific test correctly identifies individuals who do not have a particular disease. In this case, since the lab culture report is negative for the suspected infection, it means the test is good at ruling out the disease. 'Sensitive' (choice B) would be incorrect as sensitivity refers to a test's ability to correctly identify individuals who do have the disease. 'Negative culture' (choice C) is incorrect as it describes the result rather than the test's characteristic. 'Marginal finding' (choice D) is unrelated to the concept of correctly identifying individuals without the disease.

2. For a client requiring total oral care, it is important for the nurse to:

• A. assemble all equipment, assist the client to a semi-Fowler's position, and place a towel on his chest.
• B. place the client in Fowler's position, prepare the equipment, and instruct the client what to do.
• C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
• D. use gloves and clean the client's mouth, including the tongue.

Correct answer: C

Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

3. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?

• A. "Because it gives you comfort, you may wear it."?
• B. "It is a violation of religious rights to forbid it."?
• C. "I am sorry, but it is not safe for you to wear the crucifix during this test."?
• D. "You may wear it because it is important to you."?

Correct answer: C

Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.

4. A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the healthcare provider. The healthcare provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to ask that the chest tube be removed. Which action should the nurse take first?

• A. Explain the procedure to the client, then remove the chest tube.
• B. Call the nursing supervisor.
• C. Inform the healthcare provider that removal of a chest tube is not a nursing procedure.
• D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube.

Correct answer: C

Rationale: The correct action for the nurse to take first is to inform the healthcare provider that removal of a chest tube is not a nursing procedure. Actual removal of a chest tube is the duty of a healthcare provider. If the healthcare provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies' policies and procedures may permit an advanced practice nurse to remove a chest tube, but there is no information in the question to indicate that the nurse is an advanced practice nurse. Choice A is incorrect because the nurse should not proceed with removing the chest tube without proper authorization. Choice B is incorrect as calling the nursing supervisor should come after clarifying with the healthcare provider. Choice D is incorrect as the nurse should not begin the process of removing the chest tube without proper guidance and authorization.

5. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?

• A. Performing a physical assessment prior to administration
• B. Obtaining the most recent lab values regarding renal function
• C. Reviewing peaks and troughs for the past few days
• D. Ensuring the client is not allergic to the medication

Correct answer: D

Rationale: Before administering any medication, including IV Vancomycin, it is crucial to ensure that the client is not allergic to the medication. This is the most critical action to prevent any potential allergic reactions. While performing a physical assessment is important, it may not be as time-sensitive as checking for allergies. Obtaining lab values related to renal function is also significant with Vancomycin due to its potential nephrotoxicity, but ensuring the client's safety by checking for allergies takes precedence. Reviewing peaks and troughs is important for monitoring drug levels, but it is a secondary step compared to checking for allergies prior to administration.

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