Nursing Elites

1. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Perform deep suctioning every 2 to 4 hours.
• B. Encourage the client to drink plenty of fluids.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. This intervention should be implemented first as it is non-invasive and can often effectively address the issue of thick secretions. Performing deep suctioning (Choice A) should not be the first intervention as it is more invasive and should be done based on assessment findings. Encouraging the client to drink plenty of fluids (Choice B) is beneficial but may not provide immediate relief for thick secretions. Administering a mucolytic agent (Choice D) requires a healthcare provider's prescription and should be based on assessment data and the client's condition.

2. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being... What intervention is most important for the nurse to implement?

• A. Teach the client about the use of a home pregnancy test.
• B. Schedule weekly home visits to draw hCG values.
• C. Schedule a 5-week follow-up with the healthcare provider.
• D. Begin chemotherapy administration during the first home visit.

Correct answer: B

Rationale: The most important intervention for the nurse to implement is to schedule weekly home visits to draw hCG values. Monitoring hCG levels is crucial in detecting potential complications like choriocarcinoma following GTD evacuation. Teaching about home pregnancy tests (Choice A) may not be as immediate and critical as monitoring hCG levels. A 5-week follow-up appointment (Choice C) may be too delayed for close monitoring. Initiating chemotherapy (Choice D) without appropriate hCG monitoring and evaluation is not recommended as the first-line intervention.

3. A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?

• A. Fever of 100.4°F
• B. Positive Chvostek's sign
• C. Increased joint pain
• D. Swelling in the joints

Correct answer: B

Rationale: A positive Chvostek's sign indicates hypocalcemia, which requires immediate intervention as it can lead to life-threatening complications. Fever, increased joint pain, and swelling in the joints are common symptoms in clients with rheumatoid arthritis but do not require immediate intervention like addressing hypocalcemia.

4. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab test is important for the nurse to review before contacting the healthcare provider?

• A. Capillary glucose
• B. Urine specific gravity
• C. Serum calcium
• D. White blood cell count

Correct answer: C

Rationale: The correct answer is C: Serum calcium. Numbness and tingling in the fingers and around the mouth are indicative of hypocalcemia. Serum calcium levels should be reviewed as they play a crucial role in diagnosing and managing hypocalcemia. Option A, capillary glucose, is not relevant to the symptoms described. Option B, urine specific gravity, is not typically used to assess numbness and tingling. Option D, white blood cell count, is unrelated to the symptoms presented by the client.

5. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding requires immediate intervention?

• A. Serum glucose of 300 mg/dL
• B. Serum potassium of 5.5 mEq/L
• C. Serum bicarbonate of 18 mEq/L
• D. Positive urine ketones

Correct answer: C

Rationale: A serum bicarbonate level of 18 mEq/L indicates metabolic acidosis in a client with DKA, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis, which is reflected by a low serum bicarbonate level. Correcting the low serum bicarbonate is crucial to normalize the metabolic acidosis and improve the client's condition. While elevated serum glucose (choice A) and urine ketones (choice D) are characteristic of DKA, addressing the metabolic acidosis takes precedence. Serum potassium (choice B) levels may also need monitoring and management, but correcting the acidosis is the priority to prevent complications like cardiovascular collapse.

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