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. A client who practices Islam and is currently observing dietary restrictions for the month of Ramadan. Which of the following interventions should the nurse include in the plan of care?

• A. Remove pork products from the dietary plan
• B. Facilitate fasting during daylight hours
• C. Serve meat and dairy items together
• D. Provide a low-carb diet on Fridays

Correct answer: B

Rationale: During Ramadan, individuals fast from dawn to sunset. Facilitating fasting during daylight hours respects the dietary practices of clients observing Ramadan. Choice A is incorrect as the dietary restriction during Ramadan involves abstaining from all food and drink during daylight hours, not just beef products. Choice C is incorrect as Muslims generally do not consume meat and dairy together due to religious dietary laws. Choice D is incorrect as providing a low-carb diet on Fridays does not specifically align with the dietary restrictions observed during Ramadan.

3. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

• A. inconsistent
• B. low systolic and high diastolic
• C. higher than what the reading should be
• D. lower than what the reading should be

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. A patient is being discharged with a vitamin K deficiency. What food should the nurse recommend to the patient to include in their diet?

• A. Oranges
• B. Spinach
• C. Fish
• D. Nuts

Correct answer: B

Rationale: Spinach is an excellent source of vitamin K, which plays a vital role in blood clotting and bone health. Oranges, fish, and nuts do not contain significant amounts of vitamin K, making them less suitable choices to address a vitamin K deficiency. Therefore, the correct recommendation for a patient with a vitamin K deficiency would be to include spinach in their diet to help replenish this essential vitamin.

5. When surgery is on-going, who coordinates the activities outside, including the family?

• A. Orderly/clerk C. Circulating Nurse
• B. Nurse Supervisor D. Anesthesiologist
• C.
• D.

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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