Nursing Elites

1. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?

• A. Hepatitis testing
• B. Tuberculosis screening
• C. Contraceptive teaching
• D. Colonoscopy information

Correct answer: B

Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.

2. The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?

• A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
• B. Administer 15 mL of sterile fluid into the tube prior to suctioning
• C. Suction for no longer than 30 seconds at a time
• D. Wait 30 seconds after suctioning before attempting again

Correct answer: A

Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.

3. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?

• A. Oculogyric crisis
• B. Tardive dyskinesia
• C. Nystagmus
• D. Dysphagia

Correct answer: A

Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.

4. While suctioning the endotracheal tube of an adult client, what level of pressure should the nurse apply?

• A. 70-80 mmHg
• B. 100-120 mmHg
• C. 150-170 mmHg
• D. 200 mmHg

Correct answer: B

Rationale: When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low suction pressure may not clear adequate amounts of secretions. Choice A (70-80 mmHg) is too low and may not effectively clear secretions. Choices C (150-170 mmHg) and D (200 mmHg) are too high and can potentially harm the client by causing hypoxia or damaging the airway.

5. When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?

• A. Ask the patient about any arm pain.
• B. Retake the patient's blood pressure.
• C. Check the calcium level in the chart.
• D. Notify the healthcare provider immediately.

Correct answer: C

Rationale: In this scenario, the nurse observed carpal spasms in the patient's right hand, indicating a positive Trousseau's sign, which is associated with hypocalcemia. Patients with acute pancreatitis are at risk for hypocalcemia, hence the nurse should promptly check the calcium level in the chart to assess the patient's condition. Notifying the healthcare provider comes after confirming the calcium level. There is no indication to ask about arm pain or to retake the blood pressure, as the primary concern is addressing the potential hypocalcemia.

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