Nursing Elites

1. When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?

• A. Attending to holistic client needs
• B. Ensuring client safety
• C. Avoiding medication errors
• D. Providing client-focused care

Correct answer: B

Rationale: The priority for a nurse working on an inpatient medical-surgical unit is to ensure client safety. This is crucial as errors in hospital care can lead to preventable deaths. While attending to holistic client needs and providing client-focused care are important aspects of nursing, ensuring client safety takes precedence to prevent harm and promote positive patient outcomes.

2. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

• A. Kussmaul respirations
• B. Apneustic respirations
• C. Cheyne-Stokes respirations
• D. Stridor

Correct answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

3. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding does the nurse expect?

• A. Increased anteroposterior (AP) chest diameter
• B. Decreased respiratory rate
• C. Weight gain
• D. Productive cough with yellow sputum

Correct answer: A

Rationale: Clients with COPD commonly develop a barrel chest, characterized by an increased anteroposterior diameter of the chest. This change is due to chronic air trapping and hyperinflation of the lungs. A decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typical findings in COPD. Instead, COPD patients often present with an increased respiratory rate, weight loss, and a chronic cough with sputum production.

4. A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?

• A. Would you like information about advance directives?
• B. I will arrange for a psychiatrist to speak with you.
• C. Do you want to come off the transplant list?
• D. Would you like to speak with a priest or chaplain?

Correct answer: A

Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.

5. Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?

• A. Position the head of the client's bed flat
• B. Turn the client every 4 hours
• C. Brush the client's teeth with a suction toothbrush every 12 hours
• D. Provide humidity by maintaining moisture within the ventilator tubing

Correct answer: C

Rationale: Ventilator-associated pneumonia (VAP) is a common complication in clients receiving mechanical ventilation. Oral hygiene is crucial in reducing the risk of VAP. Brushing the client's teeth with a suction toothbrush every 12 hours helps prevent bacterial colonization in the oral cavity, which can be aspirated into the lungs. Positioning the head of the bed flat can increase the risk of aspiration. Turning the client every 4 hours is important for preventing pressure ulcers but not directly related to reducing VAP. Providing humidity in the ventilator tubing helps maintain airway moisture but does not directly address the risk of VAP.

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