Nursing Elites

1. Which of the following is a critical step in preventing ventilator-associated pneumonia (VAP)?

• A. Performing oral care with chlorhexidine
• B. Elevating the head of the bed to 30-45 degrees
• C. Administering prophylactic antibiotics
• D. Changing the ventilator circuit daily

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees is a critical step in preventing ventilator-associated pneumonia (VAP) because it helps reduce the risk of aspiration, which is a significant factor in the development of VAP. Elevating the head of the bed enhances pulmonary hygiene, decreases the risk of microaspiration, and promotes better lung function. Performing oral care with chlorhexidine is essential for oral hygiene but is not specifically aimed at preventing VAP. Administering prophylactic antibiotics without a clear indication can lead to antibiotic resistance and is not a recommended routine practice to prevent VAP. Changing the ventilator circuit daily is essential for infection control but is not the most critical step in preventing VAP.

2. The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement?

• A. Obtain further data about the client's activity intolerance to position changes
• B. Advise the UAP to allow the client to rest before completing the bath
• C. Direct the UAP to obtain vital signs and a pulse oximetry reading
• D. Notify the healthcare provider about the client's episode of SOB

Correct answer: B

Rationale: Advising the UAP to allow the client to rest before completing the bath is the most appropriate action to take. This helps manage the shortness of breath (SOB) experienced by the client and prevents further stress. By giving the client time to rest, the PN ensures the client's comfort and safety during care activities. The other options are not the most immediate or appropriate actions in this scenario: obtaining further data about activity intolerance (choice A) may delay addressing the current issue, obtaining vital signs and pulse oximetry (choice C) is important but not as immediate as allowing the client to rest, and notifying the healthcare provider (choice D) is premature before trying a simple intervention like allowing the client to rest.

3. In which stage of Maslow's hierarchy of needs is a young adult attempting to achieve when deciding to change his work hours to devote more time to his community?

• A. Self-Actualization
• B. Intimacy vs. Isolation
• C. Altruism
• D. Purposefulness

Correct answer: A

Rationale: The correct answer is A: Self-Actualization. The young adult is striving for self-actualization, the highest level in Maslow's hierarchy of needs. Self-actualization is characterized by individuals seeking personal growth, self-fulfillment, and the ability to contribute to society. Choice B, Intimacy vs. Isolation, focuses on relationships and occurs at a different stage. Choice C, Altruism, although related to community contribution, does not specifically address personal growth and fulfillment as in self-actualization. Choice D, Purposefulness, is not a stage in Maslow's hierarchy of needs and is not directly relevant to the scenario described.

4. What information should the PN collect during the admission assessment of a terminally ill client to an acute care facility?

• A. Name of the funeral home to contact
• B. Client's wishes regarding organ donation
• C. Contact information for the client's next of kin
• D. Health care proxy information

Correct answer: B

Rationale: Correct Answer: B. Understanding the client's wishes regarding organ donation is crucial as it aligns with end-of-life care preferences and ensures that the client's decisions are respected. While obtaining the name of a funeral home (Choice A) may be necessary, it is not typically part of the initial admission assessment. Contact information for the client's next of kin (Choice C) is important for communication but may not be directly related to the client's immediate end-of-life wishes. Health care proxy information (Choice D) is vital for decision-making if the client becomes incapacitated but may not be the primary focus during the initial admission assessment.

5. A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. What action should the PN implement?

• A. Teach the client to use a straw when taking the medication to reduce further tooth staining
• B. Advise the client to withhold further doses until consulting with the healthcare provider
• C. Reassure the client that this change indicates the medication is having the desired effect
• D. Determine if the client is also experiencing mouth or gum pain and difficulty swallowing

Correct answer: A

Rationale: The correct action for the PN to implement is to teach the client to use a straw when taking the medication to reduce further tooth staining. Using a straw minimizes contact between the iron preparation and the teeth, helping prevent additional staining. Choice B is incorrect because withholding doses without consulting the healthcare provider could be detrimental to the client's health. Choice C is incorrect because darkening of tooth color is not an expected effect of liquid iron preparation and should not be reassured as a desired effect. Choice D is incorrect as it does not directly address the client's concern about tooth staining.

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