Nursing Elites

1. When placing a patient in the AP position for an X-ray, what position would the patient be in?

• A. Facing the X-ray film.
• B. Right side against the X-ray film.
• C. Left side against the X-ray film.
• D. Facing away from the X-ray film

Correct answer: D

Rationale: The AP position stands for Anteroposterior Projection. When a patient is in the AP position for an X-ray, they are facing away from the X-ray film. This positioning allows for a clear view of the structures being imaged from front to back. Choices A, B, and C are incorrect because the patient is not facing or positioned against the X-ray film in the AP position, but rather facing away from it to capture the necessary diagnostic information.

2. Which of the following safety precautions should the nurse discuss when working with an immunocompromised client?

• A. Avoid canned foods and increase consumption of fresh fruits and vegetables
• B. Hand-wash utensils after use and allow them to air dry
• C. Only drink tap water that has been filtered or boiled before consumption
• D. Never eat meals prepared in restaurants

Correct answer: C

Rationale: The correct answer is to only drink tap water that has been filtered or boiled before consumption. Immunocompromised clients are susceptible to infections, so it is essential to take precautions to prevent exposure to harmful pathogens. Drinking tap water that has been filtered or boiled helps eliminate potential pathogens that could be harmful to the client's health. Choices A, B, and D do not directly address the issue of avoiding potential pathogens that could compromise the health of an immunocompromised client. Thus, they are incorrect. Hand-washing utensils, avoiding canned foods, and increasing fruit and vegetable consumption are good general hygiene practices but may not specifically address the needs of an immunocompromised client.

3. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?

• A. Assign the client to stay in a negative-pressure room
• B. Use sterilized equipment when sharing between this client and another person with pertussis
• C. Wear a mask if coming within 3 feet of the client
• D. Both A and C

Correct answer: C

Rationale: When caring for a client requiring droplet precautions, it is essential for the nurse to wear a mask when within 3 feet of the client. This practice helps prevent the transmission of droplet particles that may be produced when the client coughs or sneezes. Assigning the client to a negative-pressure room is not typically necessary for droplet precautions unless specifically indicated for airborne precautions. Using sterilized equipment when sharing between clients with pertussis is important for infection control but does not directly relate to droplet precautions. Therefore, the correct action to uphold droplet precautions in this scenario is to wear a mask when coming within close proximity to the client.

4. Which of the following may represent an upper airway obstruction?

• A. Retractions
• B. Elongated expiratory phase
• C. Stridor
• D. Expiratory wheezing

Correct answer: C

Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).

5. After change-of-shift report, which patient should the nurse assess first?

• A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
• B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
• C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
• D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

Correct answer: D

Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.

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