Nursing Elites

1. What is the primary goal of performing a bed bath?

• A. To cleanse, refresh, and provide comfort to the client who must remain in bed
• B. To expose the necessary parts of the body
• C. To develop skills in bed bath
• D. To check the body temperature of the client in bed

Correct answer: A

Rationale: The primary goal of performing a bed bath is to cleanse, refresh, and provide comfort to clients who are unable to leave their bed. This helps maintain their hygiene, promotes skin health, and enhances their overall well-being. Choice B is incorrect as the primary purpose is not to expose body parts but to provide hygiene and comfort. Choice C is incorrect as the main goal is client care, not skill development. Choice D is incorrect as checking body temperature is not the main purpose of a bed bath.

2. Which instrument is used for auscultation?

• A. Percussion hammer
• B. Audiometer
• C. Stethoscope
• D. Sphygmomanometer

Correct answer: C

Rationale: Auscultation involves listening to internal sounds in the body, such as heart and lung sounds. The instrument used for auscultation is a stethoscope, which allows healthcare providers to listen to these sounds. The percussion hammer is used to elicit sounds on the body, the audiometer is used to measure hearing ability, and the sphygmomanometer is used to measure blood pressure. Therefore, the correct answer is 'Stethoscope.'

3. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

4. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

• A. Store the glasses in a labeled case.
• B. Clean the glasses with hot water
• C. Clean the glasses with a paper towel.
• D. Store the glasses on the bedside table.

Correct answer: A

Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.

5. A client is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication?

• A. Fentanyl
• B. Furosemide
• C. Famotidine
• D. Dexamethasone

Correct answer: A

Rationale: Vecuronium is a neuromuscular blocking agent used for muscle relaxation during mechanical ventilation. When administering vecuronium, it is common to also give an opioid analgesic, such as fentanyl, to manage pain and ensure the patient's comfort. Fentanyl is often used in combination with neuromuscular blocking agents to provide balanced anesthesia, making it the appropriate medication to anticipate administering in this scenario.

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