Nursing Elites

1. A nurse is reviewing the plan of care for a client who is receiving oxygen therapy. Which of the following interventions should the nurse include to prevent complications?

• A. Check the client's oxygen saturation every 2 hours
• B. Provide humidified oxygen
• C. Instruct the client to perform deep breathing exercises
• D. Use an oxygen mask for delivery

Correct answer: B

Rationale: The correct answer is B: Provide humidified oxygen. Providing humidified oxygen helps prevent dryness and irritation of the respiratory tract during oxygen therapy. This intervention is crucial in preventing complications such as mucous membrane dryness and potential damage to the airways. Checking the client's oxygen saturation every 2 hours (choice A) is essential for monitoring the client's response to therapy but does not directly prevent complications. Instructing the client to perform deep breathing exercises (choice C) is beneficial for respiratory function but does not directly address preventing complications related to oxygen therapy. Using an oxygen mask for delivery (choice D) is a common method of administering oxygen but does not specifically focus on preventing complications like dryness and irritation.

2. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.
• D. Set up the sterile field 5 cm (2 in) above waist level.

Correct answer: A

Rationale: To maintain the sterility of the field, the nurse should place the cap from the solution sterile side up on a clean surface. This action helps prevent contamination. Choice B is incorrect because opening the outermost flap toward the body increases the risk of introducing contaminants onto the sterile field. Choice C is incorrect as the sterile dressing should be placed at least 2.5 cm (1 in) from the edge of the sterile field to prevent accidental contamination. Choice D is incorrect because setting up the sterile field above waist level could lead to inadvertent contact and compromise the field's sterility.

3. Which of the following actions should the nurse take to ensure the safety of a client using home oxygen?

• A. Allow smoking in designated areas
• B. Keep oxygen tanks upright at all times
• C. Store the oxygen equipment in a closet
• D. Keep oxygen tanks at least 10 feet away from heat sources

Correct answer: B

Rationale: The correct answer is B: 'Keep oxygen tanks upright at all times.' Oxygen tanks should be stored in an upright position to prevent leaks and accidents. Choice A is incorrect as smoking should never be allowed near oxygen due to the risk of fire. Choice C is incorrect as oxygen equipment should be stored in a well-ventilated area, not in a closet. Choice D is incorrect as oxygen tanks must be kept a minimum of 5 to 10 feet away from heat sources to prevent combustion. Therefore, the best practice is to keep oxygen tanks upright to ensure safety.

4. How should a healthcare professional manage a patient with a suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants and monitor for bleeding
• B. Elevate the limb and administer pain relief
• C. Restrict mobility and apply warm compress
• D. Administer IV fluids and provide bed rest

Correct answer: A

Rationale: Corrected DVT management involves administering anticoagulants to prevent clot growth and monitoring for signs of bleeding. Elevating the limb and administering pain relief (Choice B) may help alleviate symptoms but do not address the underlying issue of preventing clot progression. Restricting mobility and applying warm compress (Choice C) could potentially dislodge the clot and worsen the condition. Administering IV fluids and providing bed rest (Choice D) are not primary interventions for managing DVT.

5. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?

• A. Increase the suction setting on the ventilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Encourage deep breathing exercises

Correct answer: B

Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.

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