Nursing Elites

1. A patient on mechanical ventilation experiences a sudden drop in oxygen saturation. What should the nurse check first?

• A. Check the ventilator tubing for disconnection.
• B. Increase the patient's oxygen flow.
• C. Perform a full physical assessment.
• D. Reassess the patient's oxygen levels after 5 minutes.

Correct answer: A

Rationale: The correct answer is to check the ventilator tubing for disconnection first when a patient on mechanical ventilation experiences a sudden drop in oxygen saturation. This is crucial because equipment malfunction, such as tubing disconnection, can lead to decreased oxygen delivery, resulting in a drop in oxygen saturation. Checking the tubing ensures that the ventilation system is functioning properly and that the patient is receiving the necessary oxygen. Option B is incorrect because increasing oxygen flow without checking for equipment issues may not address the root cause of the drop in saturation. Option C is not the priority in this situation as the immediate focus should be on assessing and ensuring the functioning of the ventilation equipment. Option D delays addressing the potential equipment malfunction, which could worsen the patient's condition if not promptly resolved.

2. Which of the following is an example of professional negligence?

• A. Following facility guidelines at all times
• B. Using equipment in a knowledgeable manner
• C. Communicating effectively with clients
• D. Documenting client interactions accurately

Correct answer: A

Rationale: Professional negligence involves failing to meet the standard of care expected in a particular profession, which can lead to harm. In this case, not following facility guidelines can result in lapses in safety or quality of care, potentially causing harm to clients. Choices B, C, and D all represent essential aspects of professional conduct and do not directly relate to negligence.

3. A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

• A. Glasgow Coma Scale (GCS) score of 12
• B. Edematous bruise on the forehead
• C. Small drops of clear fluid in the left ear
• D. Pupils are 4 mm and reactive to light

Correct answer: C

Rationale: The correct answer is C. Clear fluid draining from the ear may indicate a cerebrospinal fluid (CSF) leak, which is a serious complication following a head injury. Reporting this finding is crucial as it may require immediate medical intervention to prevent further complications. Choices A, B, and D are not as concerning as a CSF leak. A GCS score of 12 is relatively high, indicating a mild level of consciousness alteration. An edematous bruise on the forehead is a common physical finding after a head injury. Pupils that are 4 mm and reactive to light suggest normal pupillary function.

4. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?

• A. White blood cell count (WBC)
• B. C-reactive protein (CRP)
• C. Erythrocyte sedimentation rate (ESR)
• D. Hemoglobin and hematocrit levels

Correct answer: A

Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.

5. A healthcare provider is assessing a client who has been using beclomethasone for 2 weeks to manage her asthma. What is the priority to report to the provider?

• A. Sore throat
• B. Cough
• C. Chest tightness
• D. Bronchospasms

Correct answer: D

Rationale: The correct answer is D: Bronchospasms. Bronchospasms can indicate worsening asthma and are considered a severe side effect that requires immediate attention. While sore throat, cough, and chest tightness are also possible side effects of beclomethasone, bronchospasms are of higher concern due to their association with significant respiratory distress and potential exacerbation of asthma symptoms.

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