Nursing Elites

1. The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by

• A. Inserting a fenestrated catheter with a whistle tip without suction
• B. Completing the suction pass in 30 seconds with a pressure of 150 mm Hg
• C. Hyperoxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass
• D. Minimizing the suction pass to 60 seconds while slowly rotating the lubricated catheter

Correct answer: C

Rationale: Hyperoxygenating the client before and after suctioning helps prevent hypoxia by ensuring adequate oxygen levels during the procedure, which briefly interrupts the client's normal breathing pattern. Choice A is incorrect because inserting a fenestrated catheter with a whistle tip without suction would not prevent hypoxia. Choice B is incorrect as completing the suction pass in 30 seconds with a pressure of 150 mm Hg may lead to hypoxia. Choice D is incorrect as minimizing the suction pass to 60 seconds may not provide enough time for effective suctioning and could lead to hypoxia.

2. The delivery of basic health services was decentralized to the local government units. The legal basis for this is embodied in:

• A. RA 7035
• B. EO 119
• C. RA 7160
• D. PD 999

Correct answer: C

Rationale: The correct answer is C, RA 7160. This law, also known as the Local Government Code, decentralizes health services to local government units. RA 7035 is not the legal basis for decentralizing basic health services. EO 119 and PD 999 are also not the correct legal bases for the decentralization of health services.

3. A client with a urinary tract infection is receiving ciprofloxacin (Cipro). The nurse should monitor the client for which of the following side effects?

• A. Hypertension
• B. Hypoglycemia
• C. Hyperkalemia
• D. Tendonitis

Correct answer: D

Rationale: Ciprofloxacin can cause tendonitis and an increased risk of tendon rupture. Monitoring for tendonitis is crucial as it can lead to significant musculoskeletal issues. Choices A, B, and C are incorrect as hypertension, hypoglycemia, and hyperkalemia are not typically associated with ciprofloxacin use.

4. The nurse is teaching a 27-year-old client with asthma about the management of their therapeutic regimen. Which statement would indicate the need for additional instruction?

• A. ''I should monitor my peak flow every day.''
• B. ''I should contact the clinic if I am using my medication more often.''
• C. ''I need to limit my exercise, especially activities such as walking and running.''
• D. ''I should learn stress reduction and relaxation techniques.''

Correct answer: C

Rationale: Exercise, especially aerobic activities, is beneficial for clients with asthma as long as it is well-managed. Limiting exercise is not generally recommended unless specifically advised by a healthcare provider, indicating a need for further instruction in this case. Monitoring peak flow, contacting the clinic for increased medication use, and learning stress reduction techniques are all appropriate self-management strategies for asthma, indicating good understanding by the client.

5. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

• A. Focus on your sons' needs during the first days at home.
• B. Tell each child what he can do to help with the baby.
• C. Suggest that your husband spend more time with the boys.
• D. Ask the children what they would like to do for the newborn.

Correct answer: A

Rationale: The correct answer is A. Focusing on the older children's needs during the initial days at home is crucial as it helps them feel secure and valued during the transition. This approach allows the children to adjust to the new family dynamics and feel included in the care of their newborn sister. Choice B is incorrect as it focuses on tasks rather than addressing the children's emotional needs. Choice C is not the initial step and does not involve directly addressing the children's needs. Choice D puts the decision-making burden on the children rather than providing guidance and support.

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