Nursing Elites

1. When teaching a client and their family how to care for the client’s tracheostomy at home, which of the following should the nurse include?

• A. Use tracheostomy covers when outdoors
• B. Maintain a sterile technique when performing tracheostomy care
• C. Do not remove the outer cannula for routine cleaning
• D. Clean around the stoma with normal saline solution

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice D) is not advisable as it can be irritating to the skin and may impair the healing process.

2. What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?

• A. Place the pillow under the patient's head and shoulders.
• B. Attempt to do it alone if the bed is in a flat position.
• C. Place the side rails in the up position.
• D. Use a friction-reducing device.

Correct answer: D

Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.

3. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?

• A. Administer nitroglycerin sublingually.
• B. Obtain a 12-lead ECG.
• C. Measure the client's vital signs.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.

4. A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?

• A. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions
• B. A client who has a new colostomy refuses to follow instructions from the ostomy therapist because she 'doesn’t like him'
• C. The family of a client who has a terminal illness asks that the provider not disclose the diagnosis to the client
• D. A client who has Crohn’s disease reports that his prescription drug plan will not cover his medications

Correct answer: C

Rationale: The correct answer is C. It is an ethical dilemma when the family of a client with a terminal illness asks healthcare providers not to inform the client of their diagnosis. This situation poses a conflict between respecting the client's right to know the truth about their condition (autonomy and truth-telling principles) and honoring the family's wishes. Choices A, B, and D do not present ethical dilemmas. Choice A involves professional accountability and responsibility, Choice B involves a client's personal preference, and Choice D involves financial challenges.

5. A client with a tracheostomy collar has a decrease in heart rate and oxygen saturation during tracheal suctioning. Which of the following actions should the nurse take?

• A. Elevate the head of the bed.
• B. Remove the inner cannula.
• C. Irrigate the stoma.
• D. Discontinue suctioning.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to discontinue suctioning. Suctioning should be stopped immediately to prevent further decrease in heart rate and oxygen saturation. Elevating the head of the bed may help with oxygenation, but the priority is to stop the suctioning procedure. Removing the inner cannula or irrigating the stoma are not appropriate actions and could worsen the client's condition.

Similar Questions