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. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

• A. Explain the experience of having delirium
• B. Resume a normal sleep-wake cycle
• C. Regain orientation to time and place
• D. Establish normal bowel and bladder function

Correct answer: C

Rationale: Regaining orientation to time and place is a realistic short-term goal for clients with delirium. It helps the individual become aware of their surroundings and current situation, aiding in reducing confusion and disorientation. Choice A is incorrect because the goal is focused on the client's understanding, not on explaining the experience of delirium. Choice B, resuming a normal sleep-wake cycle, may take longer than 2 to 3 days to achieve and is not directly related to regaining orientation. Choice D, establishing normal bowel and bladder function, is important but may not be a short-term goal specifically related to delirium.

3. How should a healthcare provider respond to a patient experiencing acute chest pain?

• A. Administer prescribed nitroglycerin
• B. Provide oxygen
• C. Call for emergency assistance
• D. Reassure the patient

Correct answer: A

Rationale: In the case of a patient experiencing acute chest pain, the initial response should include administering prescribed nitroglycerin. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, which can be beneficial in managing chest pain related to cardiac issues. Providing oxygen can also be helpful to support oxygenation. However, the priority in this scenario is to address the potential cardiac cause by administering nitroglycerin. Calling for emergency assistance is crucial if the patient's condition does not improve or deteriorates. Reassuring the patient is essential for emotional support but should not be the primary intervention in the case of acute chest pain.

4. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

5. Which of the following findings indicates a need for immediate attention in a client diagnosed with delirium?

• A. Confusion and disorientation that resolve with rest
• B. A blood pressure reading of 110/70
• C. Irritability and agitation that worsen throughout the day
• D. Mild confusion during the evening hours

Correct answer: C

Rationale: The correct answer is C: Irritability and agitation that worsen throughout the day. These symptoms are concerning in a client diagnosed with delirium as they may indicate an exacerbation of the condition or an underlying cause that requires immediate attention. Option A describes symptoms that resolve with rest, which may not be as urgent. Option B provides a normal blood pressure reading, which is not typically associated with immediate attention in delirium cases. Option D describes mild confusion during specific hours, which may not be as critical as worsening symptoms throughout the day.

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