Nursing Elites

1. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?

• A. Impaired verbalization
• B. Depressed mood
• C. Flat affect
• D. Diminished LOC

Correct answer: C

Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.

2. Which of the following is a primary intervention for a patient experiencing hypoglycemia?

• A. Administering insulin
• B. Providing a complex carbohydrate meal
• C. Giving 15 grams of a fast-acting carbohydrate, like glucose tablets
• D. Encouraging the patient to exercise

Correct answer: C

Rationale: Giving 15 grams of a fast-acting carbohydrate, such as glucose tablets, is the primary intervention for hypoglycemia. This rapid-acting carbohydrate helps quickly raise blood sugar levels, providing immediate relief to the patient. Administering insulin (Choice A) would further lower blood sugar levels, exacerbating the hypoglycemia. Providing a complex carbohydrate meal (Choice B) would not act quickly enough to address the immediate low blood sugar issue. Encouraging the patient to exercise (Choice D) is inappropriate during hypoglycemia as it can further deplete glucose levels.

3. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?

• A. The client's bladder for distension.
• B. The IV catheter insertion site.
• C. The patency of the urinary catheter.
• D. The client's vital signs.

Correct answer: C

Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.

4. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

• A. Providing humidified oxygen
• B. Ensuring the tracheostomy ties are secure
• C. Suctioning the tracheostomy tube as needed
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

5. 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.

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