Nursing Elites

1. A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

• A. Patency of the intravenous line
• B. Level of pain
• C. Integrity of the dressing
• D. Need for suctioning

Correct answer: D

Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.

2. While dining at a restaurant, a person begins to choke. Which of the following actions should the nurse take?

• A. Instruct the person to call 911.
• B. Ask the person if he/she can speak.
• C. Use the jaw-thrust maneuver.
• D. Perform abdominal thrusts.

Correct answer: B

Rationale: When encountering a choking individual, the nurse should first assess the person's ability to speak. If the person can speak, it indicates that their airway is partially obstructed, allowing some air to pass. In this case, encouraging the person to continue coughing and monitoring them closely may be appropriate. If the person cannot speak, it may suggest a complete airway obstruction and immediate intervention is required. Instructing the person to call 911 (Choice A) may be necessary if the situation worsens. Using the jaw-thrust maneuver (Choice C) is not appropriate for a choking victim. Performing abdominal thrusts (Choice D) is typically recommended for conscious choking victims, not chest compressions.

3. Prior to a cardiac catheterization, what is the most important action for the nurse to take?

• A. Ensure that the client has been NPO for 6 hours before the procedure.
• B. Administer pre-procedure medications as ordered.
• C. Verify that informed consent has been obtained.
• D. Assess the client for any allergies, especially to iodine or shellfish.

Correct answer: D

Rationale: Assessing the client for allergies, particularly to iodine or shellfish, is crucial before a cardiac catheterization because the contrast dye used during the procedure can lead to allergic reactions. Identifying any allergies beforehand allows the healthcare team to take necessary precautions to prevent potential adverse reactions and ensure the client's safety.

4. A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?

• A. Decreased chest expansion
• B. Cyanosis
• C. Pursed-lip breathing
• D. Bradypnea

Correct answer: C

Rationale: Pursed-lip breathing is a common manifestation in clients with emphysema. It helps to increase the duration of exhalation and reduce air trapping, aiding in the management of the condition. Decreased chest expansion and bradypnea are not typically associated with emphysema. While cyanosis can occur in severe cases, pursed-lip breathing is a more specific and commonly observed sign of emphysema.

5. A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?

• A. Rifampin
• B. Isoniazid
• C. Acyclovir
• D. Pyrazinamide

Correct answer: C

Rationale: Acyclovir is an antiviral medication used to treat herpes virus infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all commonly used in the treatment of tuberculosis. Therefore, the nurse should not plan to administer Acyclovir to a client with tuberculosis.

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