Nursing Elites

1. When should a nurse suction a client with a tracheostomy?

• A. Every 6 hours, regardless of distress signs
• B. When the client's respiratory rate drops below 10
• C. When the client shows signs of irritability
• D. When the client begins to cough or show signs of airway blockage

Correct answer: C

Rationale: The correct answer is to suction the client when they show signs of irritability. Signs of irritability, such as restlessness or agitation, can indicate the need for suctioning in a client with a tracheostomy. This early indicator suggests that there may be an accumulation of secretions affecting the client's airway. Suctioning should be performed promptly to maintain a clear airway and prevent complications. Choices A, B, and D are incorrect because suctioning should be based on clinical signs and symptoms indicating the need for intervention, rather than a fixed schedule or specific vital sign parameters.

2. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

• A. Canned soup
• B. Grilled chicken
• C. Peanut butter
• D. Orange juice

Correct answer: B

Rationale: Grilled chicken is the correct choice as it is a low-potassium, low-sodium option suitable for clients with chronic kidney disease. Canned soup (choice A) is typically high in sodium, which is not recommended for this client population. Peanut butter (choice C) is high in potassium and phosphorus, which should be limited in individuals with kidney disease. Orange juice (choice D) is high in potassium and should be consumed in moderation by clients with chronic kidney disease.

3. What are the key considerations for managing a patient with COPD?

• A. Bronchodilators
• B. Smoking cessation
• C. Pulmonary rehabilitation
• D. Oxygen therapy

Correct answer: D

Rationale: The key considerations for managing a patient with COPD include oxygen therapy, which is essential to maintain adequate oxygen saturation levels. While bronchodilators are commonly used to manage COPD symptoms, they are not the primary consideration. Smoking cessation is crucial in preventing further damage but is not a direct management consideration. Pulmonary rehabilitation is beneficial for improving exercise capacity and quality of life but is not as crucial as ensuring adequate oxygen therapy.

4. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?

• A. Decerebrate posturing.
• B. Hypervigilance.
• C. Absence of deep tendon reflexes.
• D. Glasgow Coma Scale score of 15.

Correct answer: A

Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.

5. A nurse is teaching a client who has irritable bowel syndrome (IBS) about dietary modifications. Which of the following instructions should the nurse include?

• A. Increase fiber intake to 35 grams per day
• B. Avoid dairy products
• C. Eat small, frequent meals
• D. Avoid fruits and vegetables

Correct answer: C

Rationale: The correct answer is C: 'Eat small, frequent meals.' Eating small, frequent meals helps manage IBS symptoms by avoiding overloading the digestive system. Choice A is incorrect because increasing fiber intake may worsen symptoms in some individuals with IBS. Choice B is not a blanket recommendation for all IBS patients; some may tolerate dairy products well. Choice D is incorrect as fruits and vegetables are important sources of nutrients and should not be completely avoided unless specific triggers are identified.

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