Nursing Elites

1. A client with a tracheostomy is exhibiting signs of respiratory distress. What should the nurse do first?

• A. Notify the healthcare provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the priority action is to suction the tracheostomy to clear the airway and improve breathing. This helps remove secretions or blockages that may be causing the distress. Notifying the healthcare provider (Choice A) can be done after ensuring immediate airway clearance. Administering a bronchodilator (Choice C) would not address the primary issue of airway clearance in a tracheostomy patient. Increasing the oxygen flow rate (Choice D) may be necessary but should come after ensuring the airway is clear.

2. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?

• A. Iron 90 mcg/dl.
• B. Prealbumin 10 mcg/dl.
• C. Serum creatinine 0.8 mg/dl.
• D. Calcium 9.5 mg/dl.

Correct answer: B

Rationale: Corrected Rationale: Low prealbumin levels are indicative of malnutrition, which is common in individuals with anorexia nervosa. Iron levels, serum creatinine, and calcium levels are not typically affected in the same way by anorexia nervosa, making choices A, C, and D incorrect.

3. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

• A. Weight gain.
• B. Dry mouth.
• C. Sedation.
• D. Shuffling gait.

Correct answer: D

Rationale: The correct answer is D: Shuffling gait. A shuffling gait can indicate extrapyramidal symptoms, a potentially serious side effect of haloperidol. Extrapyramidal symptoms include movement disorders such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. Reporting this symptom promptly is crucial to prevent further complications. Choices A, B, and C are common side effects of haloperidol but are not as urgent or indicative of serious complications compared to a shuffling gait.

4. When caring for a client with a wound infection, what should the nurse prioritize?

• A. Change the dressing daily
• B. Cleanse the wound with an antiseptic solution
• C. Apply a wet-to-dry dressing to the wound
• D. Perform a wound culture before administering antibiotics

Correct answer: D

Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.

5. Which of the following interventions should the nurse implement for a client with hyperkalemia?

• A. Administer calcium gluconate
• B. Increase fluid intake to promote potassium excretion
• C. Administer a diuretic
• D. Administer sodium bicarbonate

Correct answer: A

Rationale: The correct intervention for a client with hyperkalemia is to administer calcium gluconate. Calcium gluconate helps counteract the effects of hyperkalemia by stabilizing the cardiac cell membrane. Increasing fluid intake (Choice B) may not effectively lower potassium levels. Administering a diuretic (Choice C) or sodium bicarbonate (Choice D) is not the primary treatment for hyperkalemia and may not address the immediate need to lower potassium levels.

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