Nursing Elites

1. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

• A. Percussion uses only one hand, while vibration uses both hands
• B. Percussion delivers cushioned blows to the chest with cupped palms, while vibration gently shakes secretions loose
• C. In both percussion and vibration, the hands are not on top of each other, and hand action is not in tune with the client's breath
• D. Percussion slaps the chest to loosen secretions, while vibration shakes the secretions along with the inhalation

Correct answer: D

Rationale: Chest percussion involves the use of rhythmic tapping to dislodge mucus from the lungs, facilitating its movement toward the larger airways where it can be expelled. This technique is particularly important in conditions where mucus retention is a significant risk factor for infection. The key difference between chest percussion and vibration is that percussion involves slapping the chest to loosen secretions, while vibration involves shaking the secretions along with the inhalation, aiding in moving the loosened secretions upwards for easier removal. Choices A, B, and C do not accurately describe the main difference between chest percussion and vibration, making them incorrect.

2. Baby John develops hyperbilirubinemia. What is a method used to treat hyperbilirubinemia in a newborn?

• A. Keeping infants in a warm and dark environment
• B. Administration of cardiovascular stimulant
• C. Gentle exercise to stop muscle breakdown
• D. Early feeding to speed passage of meconium

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. A client who is postpartum and has been diagnosed with iron deficiency anemia should be taught to consume which of the following dietary recommendations?

• A. Yogurt and mozzarella
• B. Spinach and beef
• C. Milk and turkey slices
• D. Fish and cottage cheese

Correct answer: C

Rationale: The correct answer is spinach and beef. Both spinach and beef are high in iron, making them excellent choices to help combat iron deficiency anemia. Yogurt, mozzarella, milk, turkey slices, fish, and cottage cheese are not as rich in iron compared to spinach and beef, so they are not the most suitable dietary recommendations for a client with iron deficiency anemia.

4. Among people who are ill, significant weight loss may be masked by?

• A. dehydration
• B. a large tumor
• C. drug therapy
• D. fluid retention

Correct answer: D

Rationale: Fluid retention can mask weight loss in ill individuals as the retained fluid adds to body weight, making it difficult to detect true fat or muscle loss. Dehydration (Choice A) would actually lead to weight loss rather than masking it. While a large tumor (Choice B) could contribute to weight loss, it would not mask the weight loss itself. Drug therapy (Choice C) may cause side effects, including weight changes, but it is unlikely to mask significant weight loss in the same way that fluid retention does.

5. A client has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

• A. Providing a straw for consumption of liquids
• B. Encouraging larger bites
• C. Placing the client in semi-Fowler's position during meals
• D. Instructing the client to tilt head forward when swallowing

Correct answer: C

Rationale: Placing the client in semi-Fowler's position during meals is the correct intervention for a client with acute dysphagia. This position helps prevent aspiration by facilitating swallowing. Providing a straw for consumption of liquids (Choice A) can increase the risk of aspiration and is not recommended for clients with dysphagia. Encouraging larger bites (Choice B) can also increase the risk of choking and aspiration. Instructing the client to tilt the head forward when swallowing (Choice D) is not the recommended technique for managing dysphagia as it does not address the underlying issue effectively.

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