Nursing Elites

1. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:

• A. Set and turn on the alarm of the oximeter
• B. Do nothing since there is no identified problem
• C. Cover the fingertip sensor with a towel or bedsheet
• D. Change the location of the sensor every four hours

Correct answer: B

Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.

2. 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.

3. One of the following statements is true with regards to the care of clients with depression:

• A. Only mentally ill persons commit suicide
• B. All depressed clients are considered potentially suicidal
• C. Most suicidal person gives no warning
• D. The chance of suicide lessens as depression lessens

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.

4. A client is on a 2,000-calorie American Diabetes Association (ADA) diet and substitutes whole milk with skim milk. Which of the following items can the client add to the oatmeal on his breakfast tray?

• A. One 1/8 teaspoon of salt
• B. One ounce of raisins
• C. One tablespoon of low-fat margarine
• D. One teaspoon of brown sugar

Correct answer: B

Rationale: The correct answer is one ounce of raisins. Raisins are a healthy option to add to oatmeal as they provide natural sweetness without added sugars. They are a good source of fiber and essential nutrients. Option A, one 1/8 teaspoon of salt, is not necessary for flavoring oatmeal. Option C, one tablespoon of low-fat margarine, may add unnecessary fat to the meal. Option D, one teaspoon of brown sugar, adds extra sugar, which should be limited in a diabetes-friendly diet.

5. The RR nurse should monitor for the most common postoperative complication of:

• A. hemorrhage
• B. endotracheal tube perforation
• C. osopharyngeal edema
• D. epiglottis

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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