Nursing Elites

1. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?

• A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
• B. Place a humidifier in the patient’s room
• C. Continue administering oxygen by high humidity face mask
• D. Perform chest physiotherapy on a regular schedule

Correct answer: D

Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.

2. A healthcare provider is assessing a client who has left-sided heart failure. Which of the following should the healthcare provider identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Pulmonary congestion is a common manifestation of left-sided heart failure. When the left side of the heart fails, blood backs up into the lungs, leading to pulmonary congestion. This can result in symptoms such as frothy, pink-tinged sputum due to the presence of blood in the respiratory secretions. Jugular vein distention, weight gain, and bradypnea are also associated with heart failure, but frothy, pink sputum specifically indicates pulmonary congestion in this scenario.

3. 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.

4. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?

• A. Hyperthyroidism.
• B. Thrombophlebitis.
• C. Diverticulosis.
• D. Hypocalcemia.

Correct answer: B

Rationale: Thrombophlebitis, which is inflammation of a vein with the formation of a clot, is a contraindication to the use of oral contraceptives due to an increased risk of thromboembolism. Clients with a history of thrombophlebitis or thromboembolic disorders should avoid oral contraceptives to prevent further complications like deep vein thrombosis or pulmonary embolism.

5. What is the best description of resonance?

• A. Sounds created by air-filled structures
• B. Short, high-pitched, and thudding
• C. Moderately loud with a musical quality
• D. Drum-like

Correct answer: A

Rationale: Resonance refers to the quality of sound produced by vibrations that are reinforced by other vibrations of the same frequency. In the context of the human body, resonance is often associated with sounds produced by air-filled structures like the lungs, vocal cords, and resonating cavities. Therefore, the best description of resonance from the given options is 'Sounds created by air-filled structures.' This choice aligns with the concept of resonance as it relates to sound production in the human body. Choices B, C, and D are incorrect as they do not specifically relate to the concept of resonance or its association with air-filled structures.

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