Nursing Elites

1. A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.

2. The nurse is preparing to administer medications to a client with a nasogastric tube. Which action should the nurse take first?

• A. Check for tube placement
• B. Crush the medications
• C. Flush the tube with water
• D. Administer the medications

Correct answer: A

Rationale: The correct first action when administering medications to a client with a nasogastric tube is to check for tube placement. This is crucial to ensure that the medications are delivered to the correct location within the gastrointestinal tract. Checking the tube placement helps prevent complications such as medication entering the lungs if the tube is misplaced. Crushing the medications (choice B) or flushing the tube with water (choice C) should only be done after confirming the correct tube placement. Administering the medications (choice D) without verifying the tube placement can lead to serious consequences.

3. A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?

• A. Risk for impaired tissue integrity related to impaired physical mobility
• B. Impaired skin integrity related to altered circulation and pressure
• C. Ineffective tissue perfusion related to inability to move self in bed
• D. Impaired physical mobility related to the left side paralysis

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.

4. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?

• A. Empty the bladder using an indwelling urinary catheter
• B. Increase the rate of the IV containing oxytocin (Pitocin)
• C. Assess for shock by determining the blood pressure
• D. Perform gentle massage at the level of the umbilicus

Correct answer: D

Rationale: Gentle massage at the level of the umbilicus is the initial intervention to help contract the uterus and reduce bleeding, which is crucial in managing postpartum hemorrhage. Emptying the bladder can help with fundal displacement, but massage should be done first to stimulate uterine contractions. Increasing the IV oxytocin rate is a possible intervention but not the initial priority. Assessing for shock is important, but addressing the uterine atony through massage takes precedence to prevent further hemorrhage.

5. The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?

• A. Destroy any hidden supplies of alcohol she has at home so she has to stay sober
• B. When she drinks, communicate how disruptive her behaviors are and the burden they inflict on the family
• C. Make her responsible for the consequences of her drinking behaviors
• D. Include her in family activities whether she is drinking or sober

Correct answer: C

Rationale: The best approach for the nurse to suggest is to make the woman responsible for the consequences of her drinking behaviors. By holding her accountable, she is more likely to recognize the impact of her actions and potentially initiate change. Destroying hidden alcohol supplies (Choice A) might lead to conflict and further secretive behavior. Simply communicating the disruptions caused by her drinking (Choice B) may not effectively address the issue. Including her in family activities regardless of her drinking status (Choice D) could enable the behavior and not address the underlying problem.

Similar Questions