Nursing Elites

1. When performing nasotracheal suctioning on a client with a respiratory infection, what technique should be used?

• A. Apply intermittent suction when withdrawing the catheter.
• B. Apply continuous suction during insertion of the catheter.
• C. Apply suction only during insertion of the catheter.
• D. Insert the catheter while the client is exhaling.

Correct answer: A

Rationale: The correct technique for nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps prevent damage to the mucosa and is the recommended approach. Continuous suction during insertion (choice B) can cause trauma to the airway lining. Applying suction only during insertion (choice C) is not sufficient for effective removal of secretions. Inserting the catheter while the client is exhaling (choice D) does not follow the standard procedure for nasotracheal suctioning.

2. A client with a terminal illness is being cared for by a nurse. Which of the following findings indicates that the client's death is imminent?

• A. Cold extremities
• B. Increased appetite
• C. Elevated blood pressure
• D. Increased level of consciousness

Correct answer: A

Rationale: Cold extremities are a common sign observed in clients nearing death. This occurs due to decreased blood circulation as the body's systems begin to shut down. Cold extremities indicate poor perfusion and reduced function of vital organs. Increased appetite (Choice B) is not typically seen in clients approaching death; instead, a decreased appetite is more common. Elevated blood pressure (Choice C) is not a typical finding in clients nearing the end of life, as blood pressure tends to decrease. An increased level of consciousness (Choice D) is also not indicative of imminent death, as clients near death often experience decreased level of consciousness or become unresponsive.

3. The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

• A. Assess surfaces exposed to the edges of the cast for pressure areas.
• B. Keep the patient's blood pressure low to prevent overperfusion of tissue.
• C. Allow turning in bed to prevent complications.
• D. Encourage the patient's dietary intake to maintain hydration.

Correct answer: A

Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.

4. The healthcare provider is preparing to administer a subcutaneous injection of heparin. Which site is most appropriate for the healthcare provider to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Abdomen
• D. Dorsogluteal site

Correct answer: C

Rationale: The abdomen is the most appropriate site for administering subcutaneous heparin injections. The abdomen has a layer of subcutaneous fat and a good blood supply, making it an ideal site for subcutaneous injections. Using the deltoid muscle for heparin injections is not appropriate as it is typically used for intramuscular injections. The ventrogluteal site is more suitable for intramuscular injections rather than subcutaneous injections. The dorsogluteal site is no longer recommended for injections due to the risk of injury to the sciatic nerve.

5. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Census overdue

Correct answer: A

Rationale: The correct answer is A: Temperature. A high fever is a significant indicator of infection or other serious conditions, making it the priority finding. Elevated temperature indicates an immediate concern for infection, which can quickly escalate and lead to severe complications if not addressed promptly. While heart rate, abdominal tenderness, and census overdue are important aspects to consider in the client's care, addressing the fever takes precedence due to its potential severity and implications for the client's health.

Similar Questions