Nursing Elites

1. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?

• A. Remind the client that her parents have passed away
• B. Ask the client about her favorite memories with her parents
• C. Engage the client in an activity to distract her from thinking about her parents
• D. Reorient the client to the present reality and surroundings

Correct answer: C

Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.

2. When suctioning a tracheostomy, which action is most appropriate for the nurse to take?

• A. Use a sterile tube each time and suction for 30 seconds.
• B. Use sterile technique and turn the suction off as the catheter is introduced.
• C. Use clean technique and suction for 10 seconds.
• D. Discard the catheter at the end of every shift.

Correct answer: B

Rationale: When suctioning a tracheostomy, it is crucial to use sterile technique to prevent infections. Turning off the suction as the catheter is introduced is important to avoid trauma and injury to the tracheal walls. This technique helps maintain the integrity of the tracheostomy site and ensures proper care for the patient.

3. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

• A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
• B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
• C. Assist the client to a standing position by gently lifting upward underneath the axillae.
• D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Correct answer: B

Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.

4. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

• A. The client's respiratory rate is 14 breaths per minute.
• B. The client's oxygen saturation is 92%.
• C. The client reports shortness of breath.
• D. The client's respiratory rate is 24 breaths per minute.

Correct answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A) is within an acceptable range for a client with COPD and does not require immediate action. An oxygen saturation of 92% (B) is slightly lower but still acceptable in COPD patients. Although a respiratory rate of 24 (D) is higher, it is not as immediately concerning as shortness of breath in this context.

5. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

• A. Suction deeper to remove secretions.
• B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
• C. Remove the suction as quickly as possible.
• D. Insert and remove the suction multiple times to clear secretions.

Correct answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.

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