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 healthcare professional is reviewing the medical record of a client who has hypocalcemia. The healthcare professional should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?

• A. Crohn’s disease
• B. Postoperative status following appendectomy
• C. History of bone cancer
• D. Hyperthyroidism

Correct answer: A

Rationale: Crohn’s disease is known to impair calcium absorption, which can lead to hypocalcemia. This condition affects the intestines and can disrupt the normal absorption of nutrients, including calcium. Postoperative status following appendectomy, history of bone cancer, and hyperthyroidism are typically not directly associated with a higher risk of developing hypocalcemia compared to Crohn’s disease.

3. A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

• A. Dandruff
• B. Alopecia
• C. Pediculosis
• D. Xerostomia

Correct answer: A

Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.

4. A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

• A. 8 mL/hr
• B. 10 mL/hr
• C. 12 mL/hr
• D. 15 mL/hr

Correct answer: A

Rationale: To calculate the infusion rate, use the formula: (Desired units/hr / Total units) × Volume. In this case, it would be (800 units/hr / 25,000 units) × 250 mL = 8 mL/hr. Therefore, the nurse should set the infusion pump at 8 mL/hr. Choice B, 10 mL/hr, is incorrect because it does not match the calculated rate. Choices C and D, 12 mL/hr and 15 mL/hr respectively, are also incorrect as they do not align with the correct calculation based on the provided data.

5. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

• A. Use gentle suction to prevent tissue damage.
• B. Instruct the patient to blow their nose forcefully to clear the passage.
• C. Place a dry washcloth under the nose to absorb secretions.
• D. Insert a cotton-tipped applicator into the back of the nose.

Correct answer: A

Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (Choice B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (Choice C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (Choice D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.

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