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. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has sinus arrhythmia and is receiving monitoring.
• B. A client who has a hip fracture and a new onset of tachypnea.
• C. A client who has epidural analgesia and weakness in the lower extremities.
• D. A client who has diabetes and a hemoglobin A1C of 6.8%.

Correct answer: B

Rationale: The correct answer is B because a new onset of tachypnea can indicate a respiratory complication, which requires immediate assessment. Sinus arrhythmia, epidural analgesia with weakness, and a hemoglobin A1C level of 6.8% in a client with diabetes do not pose immediate life-threatening concerns that require urgent assessment compared to the potential respiratory issues associated with tachypnea.

3. A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect?

• A. Increased urine output
• B. Increased serum sodium
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: C

Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.

4. A client is being taught about a new prescription for furosemide. Which of the following statements by the client indicates an understanding of the teaching?

• A. This medication will decrease my potassium levels.
• B. I should eat a banana every day to increase my potassium intake.
• C. I will stop taking this medication if I experience a cough.
• D. I should avoid drinking alcohol while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking furosemide should avoid alcohol because it can lead to dehydration and potential interactions with the medication. Choices A and B are incorrect because furosemide is a diuretic that can actually lower potassium levels, so the client should not expect an increase in potassium levels or solely rely on bananas for potassium intake. Choice C is incorrect because a cough is not a common side effect of furosemide and should not be a reason to stop taking the medication.

5. A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

• A. Does the doctor know you are eating that?
• B. Why are you eating seaweed soup?
• C. Of course I will heat that up for you.
• D. The hospital food is more nutritious.

Correct answer: C

Rationale: Agreeing to heat up the seaweed soup respects the client's cultural preferences and promotes a positive postpartum experience. Seaweed soup is a traditional food in some cultures, often believed to support recovery and breastfeeding. The nurse's supportive response fosters cultural sensitivity, which is crucial in providing patient-centered care.

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