Nursing Elites

1. For administering a cleansing enema, what is the common position typically used?

• A. Sims left lateral
• B. Dorsal Recumbent
• C. Supine
• D. Prone

Correct answer: A

Rationale: The correct position for administering a cleansing enema is the Sims left lateral position. This position is preferred as it helps to facilitate the procedure by allowing gravity to assist in the flow of the enema solution. The individual lies on their left side with the right knee flexed towards the chest, which helps to promote retention of the enema solution and its distribution throughout the colon. Choices B, C, and D are incorrect. The dorsal recumbent position (Choice B) is commonly used for physical examinations of the abdomen and genitalia. The supine position (Choice C) involves lying flat on the back and is not ideal for administering enemas. The prone position (Choice D) is lying flat on the stomach and is not suitable for administering enemas.

2. A healthcare provider reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3-month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The healthcare provider could be charged with:

• A. Defamation
• B. Assault
• C. Battery
• D. Malpractice

Correct answer: D

Rationale: The scenario described involves a breach of duty by the healthcare provider to properly supervise the infant, resulting in harm. This failure to meet the standard of care falls under the category of malpractice, which refers to professional negligence or misconduct. Malpractice specifically applies to situations where a healthcare provider's actions or omissions deviate from the accepted standard of care, causing harm to a patient. In this case, the nurse's lack of supervision leading to the infant falling off the scale and sustaining a skull fracture would be considered malpractice.

3. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

4. During the removal of a chest tube, what should the nurse instruct the client to do?

• A. Lie on their left side.
• B. Use the incentive spirometer.
• C. Cough at regular intervals.
• D. Perform the Valsalva maneuver.

Correct answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

5. Which of the following patients is at greatest risk for developing pressure ulcers?

• A. An alert chronic arthritic patient treated with steroids and aspirin
• B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
• C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
• D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed

Correct answer: B

Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.

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