Nursing Elites

1. A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy site with hydrogen peroxide daily.
• C. Change the tracheostomy tube weekly.
• D. Apply ointment around the tracheostomy site.

Correct answer: A

Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.

2. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

• A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
• B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
• C. The arms should be crossed over the chest or in the lap.
• D. The feet should be close together with toes pointed out.

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

3. A client is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client’s medication administration record, which of the following medications should be administered?

• A. Meperidine 75 mg IM
• B. Fentanyl 50 mcg/hr transdermal patch
• C. Morphine 2 mg IV
• D. Oxycodone 10 mg PO

Correct answer: C

Rationale: Morphine IV is the most appropriate choice for severe postoperative pain due to its rapid onset and effectiveness. Meperidine is not preferred due to its potential side effects, and fentanyl patches are typically used for chronic pain, not acute postoperative pain. Oxycodone taken orally is not ideal for providing immediate relief in this situation.

4. 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.

5. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

• A. Pad the client’s wrists before applying the restraints
• B. Tie the restraints to the side rails of the bed
• C. Secure the restraints to the bed frame
• D. Use a quick-release knot to tie the restraints

Correct answer: A

Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client’s wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.

Similar Questions