Nursing Elites

1. A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?

• A. Keep the client's extremities cold
• B. Check for strength and symmetry of peripheral pulses
• C. Keep the client's legs elevated
• D. Monitor for any constrictions, such as clothes or covers that are too tight around the legs

Correct answer: A

Rationale: Keeping the client’s extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.

2. 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.

3. There has been a serious explosion at a local factory, and many of the injured are arriving at the hospital. Which of the following patients should a nurse attend to first?

• A. A 30-year-old male who is able to walk into the hospital on his own but has numerous lacerations on the chest and face
• B. A 45-year-old male who was brought in on a stretcher, has been assessed as having respiration and circulation within normal limits, and can follow simple commands
• C. A 50-year-old woman who can walk but has a broken arm and numerous lacerations
• D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute

Correct answer: D

Rationale: The correct answer is D. The 19-year-old man with a respiration rate exceeding 30 breaths per minute is showing signs of respiratory distress, indicating a potentially life-threatening condition that requires immediate attention. Patients with respiratory distress should be prioritized as it is a critical condition. Choices A, B, and C describe patients with injuries that are less immediately life-threatening or who are more stable based on the provided information, so they can be attended to after the patient with respiratory distress. Therefore, the nurse should attend to the 19-year-old man first to address his respiratory distress and ensure his condition does not deteriorate further.

4. What is the primary function of surfactant in the lungs?

• A. Reduce surface tension
• B. Enhance oxygen absorption
• C. Facilitate carbon dioxide release
• D. Increase lung volume

Correct answer: A

Rationale: The primary function of surfactant in the lungs is to reduce surface tension in the alveoli. This reduction in surface tension prevents lung collapse and allows for easier breathing. It is particularly crucial in premature infants to help with lung expansion. Choice B is incorrect because surfactant primarily affects surface tension, not oxygen absorption. Choice C is incorrect because surfactant's main role is not in facilitating carbon dioxide release. Choice D is incorrect because surfactant does not directly increase lung volume; its main role is in reducing surface tension.

5. What is the correct order of steps in the nursing process?

• A. Assessment, Diagnosis, Planning, Implementation, Evaluation
• B. Planning, Implementation, Evaluation, Diagnosis, Assessment
• C. Diagnosis, Assessment, Planning, Implementation, Evaluation
• D. Implementation, Planning, Evaluation, Diagnosis, Assessment

Correct answer: A

Rationale: The correct order in the nursing process is Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment involves gathering information about the patient, Diagnosis is identifying the problem, Planning involves setting goals and outcomes, Implementation is carrying out the plan, and Evaluation is assessing the outcomes. Choices B, C, and D have the steps in the incorrect order, not following the standard nursing process framework. Therefore, the correct answer is option A.

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