Nursing Elites

1. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?

• A. Notify the family and await further instructions.
• B. Initiate CPR and call for emergency assistance.
• C. Allow the family to make decisions about care.
• D. Follow the family's wishes and perform no interventions.

Correct answer: B

Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.

2. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?

• A. Encourage the patient to perform incentive spirometry.
• B. Assist the patient in ambulating around the unit.
• C. Reposition the patient every 2 hours.
• D. Administer pain medication as prescribed.

Correct answer: A

Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.

3. A community health nurse is reviewing primary prevention strategies for West Nile virus with a group of clients in a rural health clinic. Which of the following instructions should the nurse include?

• A. Avoid exposure to deer ticks.
• B. Eliminate areas of standing water.
• C. Use a respiratory mask when cleaning bird coops.
• D. Plan outdoor activities after dusk.

Correct answer: B

Rationale: The correct answer is B: 'Eliminate areas of standing water.' This is an essential primary prevention strategy for West Nile virus as it helps prevent the breeding of mosquitoes that spread the virus. Choices A, C, and D are incorrect. Avoiding exposure to deer ticks is more relevant for Lyme disease, using a respiratory mask when cleaning bird coops is not a primary prevention strategy for West Nile virus, and planning outdoor activities after dusk does not directly address the prevention of West Nile virus transmission.

4. A nurse is assigned to care for four clients. Which client should the nurse assess first?

• A. A client with chest pain and shortness of breath
• B. A client with a fever of 100°F
• C. A client scheduled for surgery
• D. A client with stable vital signs

Correct answer: A

Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.

5. A patient on mechanical ventilation experiences a sudden drop in oxygen saturation. What should the nurse check first?

• A. Check the ventilator tubing for disconnection.
• B. Increase the patient's oxygen flow.
• C. Perform a full physical assessment.
• D. Reassess the patient's oxygen levels after 5 minutes.

Correct answer: A

Rationale: The correct answer is to check the ventilator tubing for disconnection first when a patient on mechanical ventilation experiences a sudden drop in oxygen saturation. This is crucial because equipment malfunction, such as tubing disconnection, can lead to decreased oxygen delivery, resulting in a drop in oxygen saturation. Checking the tubing ensures that the ventilation system is functioning properly and that the patient is receiving the necessary oxygen. Option B is incorrect because increasing oxygen flow without checking for equipment issues may not address the root cause of the drop in saturation. Option C is not the priority in this situation as the immediate focus should be on assessing and ensuring the functioning of the ventilation equipment. Option D delays addressing the potential equipment malfunction, which could worsen the patient's condition if not promptly resolved.

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