Nursing Elites

1. A client who is receiving mechanical ventilation and has an ideal weight of 60 kg should have the tidal volume set at which of the following?

• A. 300 mL
• B. 480 mL
• C. 800 mL
• D. 950 mL

Correct answer: B

Rationale: Tidal volume is the amount of air delivered with each breath during mechanical ventilation. A common formula used to calculate tidal volume is 6-8 mL/kg of ideal body weight. For a client with an ideal weight of 60 kg, the expected tidal volume would be 60 kg x 6-8 mL/kg = 360-480 mL. Therefore, the most appropriate choice is 480 mL (Option B), which falls within the expected range based on the client's weight.

2. A client with chronic obstructive pulmonary disease (COPD) who has been receiving oxygen therapy at 2 L/min now has a respiratory rate of 10 breaths/min. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 L/min.
• B. Administer a bronchodilator via nebulizer.
• C. Encourage the client to take deep breaths.
• D. Assess the client's mental status and level of consciousness.

Correct answer: D

Rationale: The priority action for the nurse is to assess the client's mental status and level of consciousness. This assessment helps determine if the decreased respiratory rate is affecting the client's oxygenation. By evaluating the client's mental status and level of consciousness, the nurse can promptly identify any signs of respiratory distress or hypoxia, allowing for timely intervention and appropriate adjustments to the oxygen therapy or other treatments.

3. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

• A. 1530 (3:30 PM)
• B. 1600 (4:00 PM)
• C. 1630 (4:30 PM)
• D. 1700 (5:00 PM)

Correct answer: C

Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.

4. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?

• A. Bring a list of all medications and their purposes.
• B. Keep the doctor's phone number close by.
• C. Ensure all providers wash their hands before entering the room.
• D. Document the name of each caregiver who enters the room.

Correct answer: A

Rationale: The most important action a client can take to protect against errors is to bring a list of all medications and their purposes. This helps ensure that the healthcare team has accurate information about the client's medications, reducing the risk of medication errors, which are the most common type of healthcare mistake. Knowing the medications and their purposes can also aid in preventing drug interactions and adverse effects during the surgical procedure.

5. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

• A. Insert an IV line
• B. Count the respiratory rate
• C. Administer oxygen
• D. Prepare equipment for intubation

Correct answer: B

Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.

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