Nursing Elites

1. A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?

• A. Clean around the stoma with povidone-iodine.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Use clean technique when suctioning the tracheostomy.
• D. Change tracheostomy ties weekly.

Correct answer: B

Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.

2. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

• A. Our child had chickenpox 6 months ago.
• B. Strep throat went through all the children at the day care last month.
• C. Both ears were infected over 3 months ago.
• D. Last week both feet had a fungal skin infection.

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

3. The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?

• A. Restrict the patient's mobility as much as possible.
• B. Realize the patient is unable to move extremities.
• C. Move all the patient's extremities.
• D. Further assess the patient.

Correct answer: D

Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.

4. A client who has a terminal illness asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

• A. Encourage the client to express their thoughts about death and dying
• B. Share the nurse's personal beliefs about death and dying
• C. Redirect the client to a chaplain or spiritual advisor
• D. Provide a brief overview of common religious beliefs about death and dying

Correct answer: A

Rationale: Encouraging the client to express their thoughts allows them to explore their own feelings and concerns about death. This approach empowers the client to reflect on their beliefs and values without the influence of the nurse's personal beliefs (choice B), which should remain separate in a professional setting. Redirecting the client to a chaplain or spiritual advisor (choice C) may be appropriate if the client seeks specific spiritual guidance. Providing a brief overview of common religious beliefs (choice D) may not address the client's individual questions and concerns.

5. The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?

• A. It is contagious with frequent recurrences.
• B. It is most helpful to air-dry feet after bathing.
• C. It is treated with salicylic acid.
• D. It is caused by lice.

Correct answer: A

Rationale: Athlete's foot, also known as tinea pedis, is a contagious fungal infection that can easily spread to other body parts, particularly the hands. It often recurs if not properly treated, making choice A the correct answer. Choices B and C are incorrect because while it is beneficial to air-dry feet after bathing to prevent moisture buildup, athlete's foot is commonly treated with antifungal medications, not salicylic acid. Choice D is incorrect because athlete's foot is caused by a fungal infection, not lice.

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