Nursing Elites

1. Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?

• A. Position the head of the client's bed flat
• B. Turn the client every 4 hours
• C. Brush the client's teeth with a suction toothbrush every 12 hours
• D. Provide humidity by maintaining moisture within the ventilator tubing

Correct answer: C

Rationale: Ventilator-associated pneumonia (VAP) is a common complication in clients receiving mechanical ventilation. Oral hygiene is crucial in reducing the risk of VAP. Brushing the client's teeth with a suction toothbrush every 12 hours helps prevent bacterial colonization in the oral cavity, which can be aspirated into the lungs. Positioning the head of the bed flat can increase the risk of aspiration. Turning the client every 4 hours is important for preventing pressure ulcers but not directly related to reducing VAP. Providing humidity in the ventilator tubing helps maintain airway moisture but does not directly address the risk of VAP.

2. When caring for an older adult client with a pulmonary infection, what action should the nurse take first?

• A. Encourage the client to increase fluid intake.
• B. Assess the client's level of consciousness.
• C. Raise the head of the bed to at least 45 degrees.
• D. Provide the client with humidified oxygen.

Correct answer: B

Rationale: Assessing the client's level of consciousness is the priority because it provides crucial information on the client's neurological status and response to the infection. Changes in consciousness can indicate deterioration or improvement in the client's condition, guiding further interventions and treatment.

3. A client is prescribed prednisone for asthma management. Which statement by the client indicates a need for further teaching?

• A. I will take this medication every day to prevent asthma attacks.
• B. I will avoid people with infections while taking this medication.
• C. I will take this medication with food to prevent stomach upset.
• D. I will stop taking this medication if I feel fine.

Correct answer: D

Rationale: The correct answer is D because prednisone, a corticosteroid, should not be abruptly stopped. It must be tapered off gradually to prevent adrenal insufficiency. Choices A, B, and C demonstrate proper understanding of the medication's use and side effects, emphasizing the importance of daily intake, infection prevention, and taking it with food to avoid stomach upset.

4. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?

• A. Unequal pupils
• B. Hypertension
• C. Tympany upon chest percussion
• D. Confusion

Correct answer: D

Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.

5. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

• A. Initiating oxygen therapy
• B. Providing immediate rest for the client
• C. Positioning the client in high-Fowler's
• D. Administering a nebulized beta-adrenergic

Correct answer: D

Rationale: During an acute asthma exacerbation, the priority intervention is to administer a nebulized beta-adrenergic medication, such as albuterol, to help open the airways and improve breathing. This action helps address the underlying cause of the exacerbation. Oxygen therapy may be needed but is not the priority over administering the bronchodilator. Providing rest and positioning the client in high-Fowler's are important but come after administering the medication to address the immediate breathing difficulties.

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