Nursing Elites

1. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important for the nurse to include in the discharge plan?

• A. Explain how to use communication tools.
• B. Teach tracheal suctioning techniques.
• C. Encourage self-care and independence.
• D. Demonstrate how to clean the tracheostomy site.

Correct answer: B

Rationale: The most important instruction for a client who recently underwent a tracheostomy is to teach tracheal suctioning techniques. Suctioning helps clear secretions and maintain an open airway, which is critical for the client's respiratory function and overall well-being. While communication tools, self-care, and cleaning the tracheostomy site are important aspects of care, ensuring proper suctioning techniques is crucial for preventing complications and ensuring the client's safety.

2. The nurse observes an adolescent client preparing to administer a prescribed corticosteroid medication using a metered dose inhaler. What action should the nurse take?

• A. Remind the client to hold their breath after inhaling the medication
• B. Confirm that the client has correctly shaken the inhaler
• C. Affirm that the client has correctly positioned the inhaler
• D. Ask the client if they have a spacer to use for this medication

Correct answer: A

Rationale: Corrected Rationale: Reminding the client to hold their breath after inhaling the medication is crucial as it helps ensure the medication is absorbed into the lungs. Option B is incorrect because shaking the inhaler is not directly related to the client's inhalation technique. Option C is incorrect as correct positioning of the inhaler is important but not the immediate action needed in this situation. Option D is incorrect as asking about the spacer is not the most relevant action to take at this moment.

3. Which nursing intervention has the highest priority for a multigravida who delivered twins and is at risk for postpartum hemorrhage?

• A. Maintain cold packs on the perineum for 24 hours.
• B. Assess the client's pain level frequently.
• C. Observe for appropriate interaction with the infants.
• D. Assess fundal tone and lochia flow.

Correct answer: D

Rationale: Assessing fundal tone and lochia flow is crucial in the early detection and prevention of postpartum hemorrhage. Fundal tone helps identify uterine atony, a common cause of postpartum hemorrhage, while monitoring lochia flow can indicate excessive bleeding. Cold packs on the perineum, although helpful for pain and swelling, are not the priority in this situation. Pain assessment and observing interactions with infants are important but secondary to assessing for signs of postpartum hemorrhage.

4. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client's instructions?

• A. Avoid strenuous activity for 6 weeks.
• B. Report fresh blood in the urine.
• C. Take acetaminophen for fever of 101°F.
• D. Consume 6 to 8 glasses of water daily.

Correct answer: B

Rationale: Reporting fresh blood in the urine is crucial following a TURP procedure as it may indicate a complication such as bleeding or clot formation. This symptom requires immediate attention to prevent further complications. Choices A, C, and D are important aspects of post-TURP care, but identifying and reporting fresh blood in the urine take precedence due to its association with potential serious complications.

5. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 28 breaths per minute
• C. Tidal volume of 300 ml
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: The correct answer is C. A tidal volume of 300 ml is concerning in a client with ARDS on mechanical ventilation because it indicates hypoventilation, which can lead to inadequate gas exchange and worsening respiratory status. This finding requires immediate intervention to optimize ventilation and oxygenation. Options A, B, and D are not as critical in this scenario. An oxygen saturation of 90% may be acceptable depending on the client's baseline condition and the target range set by the healthcare provider. A respiratory rate of 28 breaths per minute is slightly elevated but may not be immediately alarming. A blood pressure of 110/70 mmHg is within normal limits and does not require urgent intervention.

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