Nursing Elites

1. What is the priority action for a patient with a fever?

• A. Administer an antipyretic medication as prescribed.
• B. Assess the patient's temperature regularly.
• C. Provide cooling measures such as a cool compress.
• D. Provide the patient with blankets for comfort.

Correct answer: B

Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.

2. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

• A. Straps with quick-release buckles attached to bed side rails.
• B. Attempts to distract the patient with television are unsuccessful.
• C. Bilateral radial pulses present, 2+, hands warm to the touch.
• D. Released from restraints, active range-of-motion exercises completed.

Correct answer: C

Rationale: The correct answer is C because documenting bilateral radial pulses being present, 2+, and hands warm to the touch is crucial when caring for a patient in restraints. This information helps in monitoring circulation and assessing the patient's well-being. Choices A, B, and D are incorrect because they do not provide essential information related to the patient's safety and well-being while in restraints.

3. When caring for a client's tracheostomy at home, which instruction should the nurse include in the teaching?

• A. Clean with alcohol
• B. Cover the tracheostomy when outside
• C. Replace the tube weekly
• D. Use tap water to clean

Correct answer: B

Rationale: Covering the tracheostomy when outside is crucial as it helps prevent dust and other irritants from entering the airway, reducing the risk of complications. Cleaning with alcohol (choice A) can be too harsh for the skin around the tracheostomy site. While replacing the tube weekly (choice C) is important, it is typically done by healthcare providers. Using tap water to clean (choice D) is not recommended as it may introduce contaminants to the tracheostomy site.

4. Which action by the nurse will help prevent ventilator-associated pneumonia (VAP) in a patient on mechanical ventilation?

• A. Provide oral care every 4 hours.
• B. Reposition the patient every 2 hours.
• C. Suction the patient as needed.
• D. Administer antibiotics as prescribed.

Correct answer: A

Rationale: The correct answer is A. Providing oral care every 4 hours helps prevent ventilator-associated pneumonia by reducing the buildup of bacteria in the mouth that can be aspirated into the lungs. Repositioning the patient every 2 hours is important for preventing pressure ulcers but is not directly related to preventing VAP. Suctioning the patient as needed is essential for maintaining airway patency but does not specifically prevent VAP. Administering antibiotics as prescribed is a treatment for infections but does not prevent VAP.

5. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

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