Nursing Elites

1. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

• A. Apply a sterile dressing.
• B. Suction the tracheostomy.
• C. Remove the inner cannula.
• D. Clean the stoma with sterile saline.

Correct answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.

2. How should a healthcare professional manage a patient with fluid overload in heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor intake and output
• D. Administer diuretics

Correct answer: A

Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.

3. A nurse is providing dietary teaching to a client who has chronic pancreatitis. Which of the following foods should the nurse instruct the client to avoid?

• A. Baked chicken
• B. Grilled salmon
• C. Steamed broccoli
• D. Fried foods

Correct answer: D

Rationale: Clients with chronic pancreatitis should avoid fried foods because they are high in fat, which can exacerbate symptoms and lead to further complications. Baked chicken (choice A), grilled salmon (choice B), and steamed broccoli (choice C) are generally healthier options and can be included in a low-fat diet suitable for individuals with chronic pancreatitis.

4. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post maturity
• D. Head compression

Correct answer: D

Rationale: Corrected Rationale: Early decelerations are caused by head compression resulting from the fetal head being compressed during contractions. They are considered benign and do not indicate fetal distress. Choice A, fetal hypoxia, is incorrect because early decelerations are not associated with fetal hypoxia. Choice B, abruptio placentae, is incorrect as it is a condition where the placenta prematurely separates from the uterine wall. Choice C, post maturity, is incorrect as it refers to a fetus that remains in the uterus past the due date.

5. What is the priority intervention for a patient with a suspected pulmonary embolism?

• A. Administer oxygen
• B. Administer anticoagulants
• C. Prepare for surgery
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer oxygen. Administering oxygen is the priority intervention for a patient with a suspected pulmonary embolism to improve oxygenation levels. In pulmonary embolism, there is a blockage in one of the pulmonary arteries, leading to decreased oxygen exchange. Administering oxygen helps increase oxygen saturation levels. Anticoagulants (Choice B) are essential in the treatment of pulmonary embolism but are not the initial priority intervention. Surgery (Choice C) is not typically the first-line treatment for pulmonary embolism. Monitoring oxygen saturation (Choice D) is important but administering oxygen takes precedence as the immediate action to address hypoxemia.

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