Nursing Elites

1. When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?

• A. Assist-control
• B. Synchronized intermittent mandatory ventilation
• C. Continuous positive airway pressure
• D. Pressure support ventilation

Correct answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

2. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

• A. Apply a vest restraint if self-extubation is attempted.
• B. Monitor ventilator settings every 8 hours.
• C. Document tube placement in centimeters at the angle of the jaw.
• D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

3. What is the appropriate needle gauge for intradermal injection?

• A. 20G
• B. 22G
• C. 25G
• D. 26G

Correct answer: D

Rationale: Intradermal injections require a very fine needle to be used to deliver the medication into the dermis layer of the skin. A 26G needle is typically used for intradermal injections as it is thin enough to penetrate the skin's surface and deposit the medication accurately.

4. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?

• A. SaO2 95%
• B. Wheezing
• C. Retraction of sternal muscles
• D. Premature ventricular complexes (PVC's)

Correct answer: A

Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.

5. The client was asked to read the Snellen chart. Which of the following is being tested?

• A. Optic
• B. Olfactory
• C. Oculomotor
• D. Trochlear

Correct answer: A

Rationale: The correct answer is A: Optic. The Snellen chart is used to test visual acuity, which assesses the function of the optic nerve responsible for vision. Choices B, C, and D are incorrect. Olfactory relates to the sense of smell, oculomotor controls eye movement, and trochlear controls certain eye muscles. Therefore, the only option related to vision testing in this context is the optic nerve.

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