Nursing Elites

1. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

• A. Place the client in isolation until further assessment is completed.
• B. Seclude the client from other clients and visitors.
• C. Perform no intervention until test results confirm a diagnosis.
• D. Don personal protective equipment immediately.

Correct answer: B

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.

2. Which is the proper hand position for performing chest percussion?

• A. Use the side of the hands
• B. Flatten the hands
• C. Spread the fingers of both hands
• D. Cup the hands

Correct answer: D

Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.

3. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

• A. calcium
• B. magnesium
• C. potassium
• D. sodium chloride

Correct answer: D

Rationale: When a client with an ileus is placed on intestinal tube suction, the primary electrolyte lost is sodium chloride. Duodenal intestinal fluid contains potassium (K+), sodium (Na+), and bicarbonate. Suctioning is done to remove excess fluids, leading to a decrease in the client's sodium chloride levels. Therefore, options A, B, and C are incorrect as calcium, magnesium, and potassium are not the primary electrolytes lost during intestinal suction in a client with an ileus.

4. What is the 24-hour day-night cycle known as?

• A. circadian rhythm
• B. infradian rhythm
• C. ultradian rhythm
• D. non-REM rhythm

Correct answer: A

Rationale: The correct answer is circadian rhythm. Circadian rhythm refers to the rhythmic repetition of patterns that occur approximately every 24 hours, regulating various biological processes related to the day-night cycle. Infradian rhythm, which is longer than 24 hours, and ultradian rhythm, which is shorter than 24 hours, are not the correct terms for the 24-hour cycle. Non-REM rhythm does not specifically relate to the 24-hour day-night cycle, making it an incorrect choice.

5. When are standard walkers typically used?

• A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
• B. When clients have poor balance, have a broken leg, or have experienced amputation.
• C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
• D. When clients have poor balance, have an autoimmune disease, or have weak arms.

Correct answer: C

Rationale: Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.

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