Nursing Elites

1. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?

• A. Encourage the client to drink plenty of fluids.
• B. Perform deep suctioning every 2 to 4 hours.
• 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. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.

2. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

• A. Your baby is gaining weight right on schedule
• B. What food does your baby usually eat in a normal day?
• C. The baby is below the normal percentile for weight gain
• D. What was the baby's weight at the last well-baby check-up?

Correct answer: A

Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.

3. A client with chronic heart failure is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?

• A. Serum potassium of 3.0 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 1.5 mg/dl
• D. Blood glucose of 200 mg/dl

Correct answer: A

Rationale: A serum potassium level of 3.0 mEq/L requires immediate intervention in a client receiving furosemide. Furosemide can cause potassium loss, leading to hypokalemia, which can be dangerous, especially in patients with heart failure. Hypokalemia can predispose the client to cardiac dysrhythmias, weakness, and other complications. Therefore, prompt intervention is necessary to prevent these adverse effects. Choice B (Serum sodium of 135 mEq/L) is within the normal range and does not require immediate intervention. Choice C (Serum creatinine of 1.5 mg/dl) may indicate kidney dysfunction but does not pose an immediate threat to the client's safety. Choice D (Blood glucose of 200 mg/dl) may suggest hyperglycemia, which is important but not as urgent as addressing hypokalemia in a client with heart failure receiving furosemide.

4. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer intravenous fluids as prescribed.
• B. Monitor the client's urine output.
• C. Administer insulin as prescribed.
• D. Administer 50% dextrose IV push.

Correct answer: C

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. In DKA, there is a lack of insulin leading to hyperglycemia and ketosis. Insulin administration helps to reduce blood glucose levels and correct metabolic acidosis, which are crucial in treating DKA. Administering intravenous fluids helps with dehydration, monitoring urine output is important to assess renal function, but the priority is addressing the underlying cause of DKA by administering insulin. Administering 50% dextrose IV push is incorrect as it would further elevate blood glucose levels, which is contraindicated in DKA.

5. An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which question best assists the nurse in obtaining relevant historical data?

• A. Have you had any difficulty starting your urinary stream?
• B. Do you have a history of kidney stones?
• C. How much fluid do you drink daily?
• D. Have you had any previous urinary tract infections?

Correct answer: A

Rationale: The correct answer is A: 'Have you had any difficulty starting your urinary stream?' This question is the most relevant as difficulty starting urination can indicate an obstruction, which aligns with the client's current condition of postrenal obstruction causing acute renal failure. Choice B is incorrect as a history of kidney stones may not be directly related to the current obstruction. Choice C, asking about daily fluid intake, is not specific to the current issue of postrenal obstruction. Choice D inquires about previous urinary tract infections, which are not directly related to the current acute renal failure caused by postrenal obstruction.

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