Nursing Elites

1. When performing nasotracheal suctioning for a client with a respiratory infection, what technique should the nurse use?

• A. Apply intermittent suction when withdrawing the catheter
• B. Suction continuously while inserting the catheter
• C. Suction intermittently while inserting the catheter
• D. Use a Yankauer suction device

Correct answer: A

Rationale: When performing nasotracheal suctioning for a client with a respiratory infection, the nurse should apply intermittent suction when withdrawing the catheter. This technique helps minimize mucosal damage and is considered best practice. Choice B, suctioning continuously while inserting the catheter, is incorrect as continuous suctioning can cause trauma to the airway. Choice C, suctioning intermittently while inserting the catheter, is also incorrect as it can increase the risk of hypoxia and mucosal damage. Choice D, using a Yankauer suction device, is not appropriate for nasotracheal suctioning as it is typically used for oral suctioning. Therefore, the correct technique is to apply intermittent suction when withdrawing the catheter to ensure effective and safe suctioning.

2. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

• A. Ask the client to consider a direct donation
• B. Withhold the blood transfusion
• C. Request a consultation with the ethics committee
• D. Ask the client's family to intervene

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.

3. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Murmur
• C. S1 and S2
• D. Bruit

Correct answer: A

Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.

4. The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?

• A. Nasal congestion
• B. Cough
• C. Sore throat
• D. Fatigue

Correct answer: C

Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.

5. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

• A. Dry mucous membranes
• B. Increased urine output
• C. Decreased heart rate
• D. Elevated blood pressure

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

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