Nursing Elites

1. During a call to the on-call physician about a client who had a hysterectomy 2 days ago & has unrelieved pain from prescribed narcotic medication, which statement is part of the SBAR format for communication?

• A. I suggest ordering a different pain medication.
• B. This client has allergies to morphine & codeine.
• C. Dr. Smith does not prefer nonsteroidal anti-inflammatory meds.
• D. The client had a vaginal hysterectomy 2 days ago.

Correct answer: B

Rationale: SBAR is a structured form of communication used in healthcare settings. It stands for Situation, Background, Assessment, and Recommendation. In this scenario, informing the on-call physician about the client's allergies to morphine & codeine falls under the 'Background' component of the SBAR format, making choice B the correct answer.

2. 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.

3. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?

• A. "We can teach you some relaxation techniques to minimize your pain."
• B. "Keep wire cutters with you at all times."
• C. "Use a water pick device to keep your teeth clean."
• D. "Consume a high-protein, liquid diet."

Correct answer: B

Rationale:

4. A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)

• A. Administer prescribed albuterol (Ventolin) inhaler.
• B. Assess the client for tracheal deviation.
• C. Administer oxygen to maintain saturations greater than 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation indicates the use of accessory muscles and difficulty in moving air due to airway narrowing, supported by bilateral wheezing and decreased pulse oxygen saturation. This client needs immediate intervention as their asthma is not responding to the medication. Administering oxygen to maintain saturations above 94% is crucial to ensure adequate oxygenation. While administering a rescue inhaler could also be necessary, oxygen therapy takes priority in this situation.

5. A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

• A. Give morphine IV.
• B. Administer oxygen therapy.
• C. Start an IV infusion of lactated Ringer's.
• D. Initiate cardiac monitoring.

Correct answer: B

Rationale: Administering oxygen therapy is the priority intervention for a client with a pulmonary embolism. Oxygen helps improve oxygenation levels and decrease the workload on the heart. It is crucial to ensure adequate oxygenation before other interventions are initiated. Morphine IV, starting an IV infusion of lactated Ringer's, and initiating cardiac monitoring are important interventions but come after ensuring adequate oxygenation.

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