Nursing Elites

1. The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?

• A. Perform passive range of motion to the right leg
• B. Remove skeletal weights every shift to assess right leg
• C. Turn frequently from prone to supine positions
• D. Maintain skeletal pin sites and assess for signs of infection

Correct answer: D

Rationale: Maintaining skeletal pin sites and assessing for infection are critical in skeletal traction care.

2. A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.

3. The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?

• A. Provide educational materials on smoking cessation
• B. Offer blood pressure screening and monitoring
• C. Provide information on safe sex practices
• D. Discuss the importance of a healthy diet and exercise

Correct answer: B

Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.

4. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?

• A. Use a 1-inch needle
• B. Select a large muscle for the injection
• C. Aspirate for blood return before injecting
• D. Massage the injection site

Correct answer: C

Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.

5. Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of high levels of oxygen for extended periods.
• B. Administering a sedative at bedtime to slow the client's respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: The correct answer is A: Avoiding the administration of high levels of oxygen for extended periods. Oxygen toxicity can occur when high levels of oxygen are given for a prolonged period. It is important to monitor and adjust the oxygen levels as needed to prevent toxicity. Choice B is incorrect because administering a sedative to slow the respiratory rate does not directly prevent oxygen toxicity. Choice C is incorrect as removing the nasal cannula during the night can compromise the client's oxygenation. Choice D is incorrect as running oxygen through a hydration source does not prevent oxygen toxicity; instead, it may introduce risks associated with the hydration source.

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