Nursing Elites

1. While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?

• A. Endotracheal cuff pressure greater than 25 cm H2O.
• B. Decreased lung compliance during ventilation.
• C. Bilateral crackles with increased secretions.
• D. Restless client who is biting the endotracheal tube.

Correct answer: D

Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.

2. The nurse is caring for a client with a diagnosis of bipolar disorder who is taking lithium. What is the most important information the nurse should provide?

• A. Take the medication on an empty stomach.
• B. Monitor sodium intake.
• C. Report any signs of weight gain.
• D. Avoid excessive caffeine intake.

Correct answer: B

Rationale: The correct answer is B: 'Monitor sodium intake.' Sodium levels can affect lithium levels in the body, so it is crucial to maintain a consistent sodium intake to prevent toxicity or subtherapeutic levels. Option A is incorrect because lithium is usually recommended to be taken on an empty stomach to enhance absorption. Option C, reporting signs of weight gain, is relevant but not as critical as monitoring sodium intake. Option D, avoiding excessive caffeine intake, is important for some individuals but not as essential as monitoring sodium levels when taking lithium.

3. A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

• A. Administer glucagon intramuscularly.
• B. Provide a complex carbohydrate snack.
• C. Administer 50% dextrose intravenously.
• D. Give 15 grams of a fast-acting carbohydrate.

Correct answer: D

Rationale: The correct answer is to give 15 grams of a fast-acting carbohydrate as the priority intervention in a client experiencing hypoglycemia. This helps quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is typically reserved for severe hypoglycemia where the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is not the priority in an acute hypoglycemic episode where immediate action is needed. Administering 50% dextrose intravenously (Choice C) is more invasive and usually reserved for cases where the client is unable to take anything by mouth.

4. The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?

• A. Perform hand hygiene before and after handling the catheter
• B. Change the catheter every 72 hours
• C. Apply antibiotic ointment at the insertion site
• D. Irrigate the catheter daily

Correct answer: A

Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.

5. The nurse is assessing a client with congestive heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?

• A. Sodium level
• B. Potassium level
• C. Calcium level
• D. Chloride level

Correct answer: B

Rationale: The correct answer is B: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring the potassium level is crucial to prevent complications such as cardiac arrhythmias. Sodium level (choice A) is not typically affected by furosemide. Calcium level (choice C) and chloride level (choice D) are also not the primary focus of monitoring when a client is on furosemide for heart failure.

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