Nursing Elites

1. 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.

2. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?

• A. "It might help if I tried sleeping only on my back."
• B. "I'll sleep better if I take a sleeping pill at night."
• C. "I'll get a humidifier to run at my bedside at night."
• D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."

Correct answer: D

Rationale:

3. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)

• A. Age
• B. Hypertension
• C. Obesity
• D. Smoking

Correct answer: B

Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor as it is a natural process of life.

4. A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

• A. Blockage of the ET tube by the client's tongue
• B. Passage of the ET tube into the esophagus
• C. Movement of the ET tube into the right main bronchus
• D. Infection of the vocal cords

Correct answer: C

Rationale: When the nurse observes the absence of left-sided chest wall expansion upon respiration, it indicates that the endotracheal tube (ET) may have migrated into the right main bronchus, leading to uneven chest expansion. This can result in inadequate ventilation to the left lung, causing respiratory compromise. The other options, such as blockage of the ET tube by the client's tongue, passage of the ET tube into the esophagus, and infection of the vocal cords, do not directly explain the observed chest wall asymmetry and respiratory distress.

5. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

• A. Encourage the client and family to be active partners.
• B. Instruct the client to monitor hand hygiene in caregivers.
• C. Offer the family the opportunity to stay with the client.
• D. Advise the client to always wear their armband.

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

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