Nursing Elites

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

• A. Perform hand hygiene
• B. Identify the client using two identifiers
• C. Prepare the sterile field
• D. Don sterile gloves

Correct answer: A

Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.

2. While measuring a client’s oral temperature using an electronic thermometer, what action should the nurse take?

• A. Assist the client with oral hygiene before taking the temperature.
• B. Inquire whether the client has smoked in the last 30 minutes.
• C. Connect the red tip probe to the thermometer unit.
• D. Position the probe tip against the client’s buccal mucosa.

Correct answer: B

Rationale: The correct action for the nurse to take when measuring a client’s oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.

3. The client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the healthcare provider monitor closely?

• A. Potassium
• B. Sodium
• C. Calcium
• D. Magnesium

Correct answer: A

Rationale: Correct! When a client is taking furosemide (Lasix), monitoring potassium levels is crucial due to the potential for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Low potassium levels can predispose the client to cardiac dysrhythmias. Sodium, calcium, and magnesium levels are not typically affected by furosemide to the same extent as potassium, making them less critical to monitor in this scenario.

4. A client with asthma is prescribed a corticosteroid inhaler. Which instruction should the nurse provide to the client to prevent a common side effect of this medication?

• A. Use the inhaler only when experiencing asthma symptoms.
• B. Rinse the mouth with water after using the inhaler.
• C. Increase fluid intake while using the inhaler.
• D. Avoid eating or drinking for 30 minutes after using the inhaler.

Correct answer: B

Rationale: The correct instruction for the client using a corticosteroid inhaler to prevent a common side effect is to rinse the mouth with water after using the inhaler. Corticosteroid inhalers can lead to oral thrush, a fungal infection in the mouth. Rinsing the mouth helps reduce the risk of developing oral thrush. Choices A, C, and D are incorrect because using the inhaler only when experiencing symptoms, increasing fluid intake, or avoiding eating/drinking for 30 minutes after use are not directly related to preventing oral thrush, which is the common side effect associated with corticosteroid inhalers.

5. A client with limited mobility in his lower extremities is being cared for by a nurse. Which of the following actions should the nurse take to prevent skin breakdown?

• A. Place the client in high-Fowler's position
• B. Increase the client's intake of carbohydrates
• C. Massage the reddened areas with unscented lotion
• D. Have the client use a trapeze bar when changing positions

Correct answer: D

Rationale: The correct answer is to have the client use a trapeze bar when changing positions. This action helps in repositioning without causing friction or shearing, which can lead to skin breakdown. Placing the client in high-Fowler's position (Choice A) may not directly prevent skin breakdown related to limited mobility. Increasing carbohydrate intake (Choice B) is not relevant to preventing skin breakdown. Massaging reddened areas with lotion (Choice C) can potentially cause more harm by increasing friction and damaging the skin further, rather than preventing breakdown.

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