Nursing Elites

1. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?

• A. corner of the mouth to the tragus of the ear
• B. corner of the eye to the top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: B

Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.

2. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. Increase maternal fluids.
• B. Administer oxygen.
• C. Decrease maternal fluids.
• D. Turn the mother.

Correct answer: C

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.

3. When making an occupied bed, what is important for the nurse to do?

• A. keep the bed in the low position.
• B. use a bath blanket or top sheet for warmth and privacy
• C. constantly keep side rails raised on both sides.
• D. move back and forth from one side to the other when adjusting the linens.

Correct answer: B

Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.

4. When a client has a chest drainage system in place, where should the system be placed?

• A. above the level of the client's chest
• B. at the level of the client's shoulders
• C. at the level of the chest
• D. below the level of the chest

Correct answer: D

Rationale: A chest drainage system should be placed below the level of the client's chest to ensure proper drainage of fluid from the chest. Placing the system above the level of the chest or at the shoulders would not allow gravity to assist in the drainage process, potentially leading to complications such as fluid accumulation. Similarly, placing it at the level of the chest would not create the necessary gravity-dependent flow for effective drainage, which is crucial for the proper functioning of the chest drainage system.

5. The physician's role in case management includes all of the following except:

• A. participating in interdisciplinary planning for clients.
• B. serving as the expert for resource utilization.
• C. consulting with the case management team to facilitate timely orders as needed.
• D. contributing to the documentation of a client's needs for services.

Correct answer: B

Rationale: The correct answer is 'serving as the expert for resource utilization.' While physicians play a crucial role in case management, their primary focus is on medical diagnosis and treatment rather than resource utilization. Choices A, C, and D are all roles that physicians typically fulfill in case management. A physician participating in interdisciplinary planning for clients ensures comprehensive care, consulting with the case management team helps in coordinating timely orders, and contributing to the documentation of a client's needs for services aids in providing appropriate care. Therefore, serving as the expert for resource utilization does not align with the primary responsibilities of a physician in case management.

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