Nursing Elites

1. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

• A. This medication is given to treat infection.
• B. This medication is given to facilitate ventilation.
• C. This medication is given to decrease inflammation.
• D. This medication is given to reduce anxiety.

Correct answer: B

Rationale: Vecuronium is a neuromuscular blocking agent that is used to facilitate ventilation by inducing muscle paralysis, which can help improve oxygenation in patients with ARDS. It does not treat infection, decrease inflammation, or reduce anxiety. Understanding the purpose of vecuronium administration is crucial for providing safe and effective care to patients with respiratory distress.

2. A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?

• A. Antibiotic
• B. Beta-blocker
• C. Antiviral
• D. Beta2 agonist

Correct answer: D

Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.

3. Which technique in physical examination is used to assess the movement of air through the tracheobronchial tree?

• A. Palpation
• B. Auscultation
• C. Inspection
• D. Percussion

Correct answer: B

Rationale: The correct answer is B: Auscultation. Auscultation is a technique in physical examination used to assess the movement of air through the tracheobronchial tree. During auscultation, healthcare providers listen to lung sounds using a stethoscope to detect abnormalities such as wheezing, crackles, or diminished breath sounds, which can indicate conditions affecting the airways or lungs. Palpation (Choice A) involves feeling the body for abnormalities, Inspection (Choice C) involves visual examination, and Percussion (Choice D) involves tapping on the body to produce sounds that can help in assessing underlying structures, but they are not directly used to assess air movement through the tracheobronchial tree.

4. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room.
• B. Place the client in a room with negative pressure.
• C. Wear gloves when providing care to the client.
• D. Wear a mask when in the client's room.

Correct answer: C

Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.

5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

• A. Oral
• B. Axillary
• C. Arterial line
• D. Rectal

Correct answer: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

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