Nursing Elites

1. When caring for an older adult client with a pulmonary infection, what action should the nurse take first?

• A. Encourage the client to increase fluid intake.
• B. Assess the client's level of consciousness.
• C. Raise the head of the bed to at least 45 degrees.
• D. Provide the client with humidified oxygen.

Correct answer: B

Rationale: Assessing the client's level of consciousness is the priority because it provides crucial information on the client's neurological status and response to the infection. Changes in consciousness can indicate deterioration or improvement in the client's condition, guiding further interventions and treatment.

2. A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?

• A. Do you have trouble breathing or chest pain?
• B. Are you able to walk upstairs without fatigue?
• C. Do you awake with breathlessness during the night?
• D. Do you have new-onset heaviness in your legs?

Correct answer: B

Rationale: Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night & peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

3. When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?

• A. Administer prescribed antibiotics on time.
• B. Encourage the client to use a tissue when coughing.
• C. Place the client in a private room.
• D. Perform hand hygiene before and after client contact.

Correct answer: D

Rationale: The most effective intervention to prevent the spread of infection when caring for a client with pneumonia is performing hand hygiene before and after client contact. This practice helps reduce the transmission of pathogens from one person to another, promoting infection control and maintaining a safe environment for both the client and healthcare provider.

4. A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?

• A. Ciprofloxacin
• B. Fluconazole
• C. Tobramycin
• D. Vancomycin

Correct answer: A

Rationale: In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.

5. In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?

• A. Airway protection
• B. Decreasing intracranial pressure
• C. Stabilizing cardiac arrhythmias
• D. Preventing musculoskeletal disability

Correct answer: A

Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.

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