Nursing Elites

1. What are the risk factors for developing pneumonia in older adults?

• A. Immobility and decreased lung function
• B. Poor hygiene and aspiration
• C. Use of respiratory equipment and medications
• D. Poor nutritional status and compromised immune system

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

2. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?

• A. Continue to monitor the fetal heart rate.
• B. Stop the oxytocin infusion.
• C. Perform a vaginal examination.
• D. Initiate an amnioinfusion.

Correct answer: A

Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.

3. A client who is to undergo an exercise stress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should eat a large meal 2 hours before the test
• B. I should avoid drinking water before the test
• C. I should stop taking my blood pressure medication
• D. I should report any chest pain during the test

Correct answer: D

Rationale: The correct answer is D: 'I should report any chest pain during the test.' This statement indicates an understanding of the teaching because reporting chest pain during an exercise stress test is crucial as it may signify cardiac distress. Choices A, B, and C are incorrect. Eating a large meal 2 hours before the test is not recommended as it may affect the results. Avoiding drinking water before the test is also not advisable as staying hydrated is important. Stopping blood pressure medication without medical advice can be dangerous, especially before a stress test.

4. What guides behavior and decision making based on values and beliefs?

• A. Morals
• B. Beliefs
• C. Ethics
• D. Autonomy

Correct answer: A

Rationale: Morals are the values and beliefs that guide behavior and decision-making. While beliefs are part of the equation, morals specifically dictate how individuals act and make choices. Ethics, on the other hand, refer to a system of moral principles governing conduct. Autonomy, although important, is not directly related to the values and beliefs that guide behavior and decision making.

5. A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

• A. Keep the client awake
• B. Instruct the client not to get out of bed
• C. Encourage the client to drink fluids
• D. Encourage early ambulation

Correct answer: B

Rationale: The correct answer is to instruct the client not to get out of bed. Lorazepam is a sedative that can cause drowsiness and impair coordination. By instructing the client not to get out of bed, the nurse helps prevent falls or injuries that could occur due to the medication's sedative effects. Choice A is incorrect as keeping the client awake may not be necessary and could lead to unnecessary discomfort. Choice C is incorrect as encouraging the client to drink fluids is not directly related to the administration of lorazepam. Choice D is incorrect as early ambulation is not safe immediately after administering a sedative medication.

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