Nursing Elites

1. In what order should the unit manager implement interventions to address the UAP’s behavior after they leave the unit without notifying the staff?

• A. Note date and time of the behavior.
• B. Discuss the issue privately with the UAP.
• C. Plan for scheduled break times.
• D. Evaluate the UAP for signs of improvement.

Correct answer: A

Rationale: The correct order for the unit manager to implement interventions to address the UAP's behavior is to first note the date and time of the behavior. Proper documentation is crucial as it provides a factual record of the incident. This documentation can be used to address the behavior effectively and to track any patterns or improvements in the future. Discussing the issue with the UAP privately (choice B) should come after documenting the behavior. Planning for scheduled break times (choice C) is unrelated to the situation described and does not address the UAP's behavior of leaving without notifying the staff. Evaluating the UAP for signs of improvement (choice D) can only be done effectively after the behavior has been addressed and interventions have been implemented.

2. The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

• A. Encourage the parents to allow the child to continue attending swimming lessons with supervision
• B. Suggest that the child be encouraged to participate in a team sport to promote socialization
• C. Explain that their child is not mature enough to understand the risks associated with swimming
• D. Provide a list of alternative activities that are less likely to cause the child to experience fatigue

Correct answer: A

Rationale: Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the most appropriate response. Swimming can be beneficial for the child, providing both exercise and enjoyment. Supervision can help manage any risks associated with swimming. Choice B is incorrect because the child's preference for swimming should be respected, and swimming can still offer socialization opportunities. Choice C is incorrect as it undermines the child's capability to understand the situation. Choice D is less appropriate as it does not address the child's interest in swimming and may limit beneficial physical activity.

3. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

• A. Increase wall suction while removing the suction catheter
• B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
• C. Suction the client’s oropharynx after tracheal suctioning
• D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

4. Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope?

• A. Pedal pulses
• B. Breath sounds
• C. Oxygen saturation
• D. Blood pressure

Correct answer: D

Rationale: The correct answer is 'D: Blood pressure.' It is crucial to check the client's blood pressure before ambulating them, especially if they have a history of syncope. Monitoring blood pressure helps to prevent falls by ensuring that the client's blood pressure is stable enough to tolerate the activity. Choices A, B, and C are not as critical in this scenario. Checking pedal pulses, breath sounds, or oxygen saturation is important but not as crucial as assessing blood pressure when preparing to ambulate a client with a history of syncope.

5. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

• A. Sluggish pupillary response to light
• B. Clear fluid leaking from the nose
• C. Complaint of severe headache
• D. Periorbital ecchymosis of the right eye

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

Similar Questions