Nursing Elites

1. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?

• A. Release the suction by opening the vent.
• B. Continue suctioning to remove obstruction.
• C. Increase the pressure.
• D. Suction deeper.

Correct answer: A

Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.

2. After surgery, a client who had a colostomy says 'I know the doctor did not really do a colostomy'. The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery. What nursing action is indicated at this time?

• A. Agree with the client until they are ready to accept the colostomy.
• B. Say 'It must be difficult to have this kind of surgery'.
• C. Force the client to look at their colostomy.
• D. Ask the surgeon to explain the surgery to the client.

Correct answer: B

Rationale: Acknowledging the client's feelings with empathy is essential in the early stage of adjustment to a colostomy surgery. By saying 'It must be difficult to have this kind of surgery,' the nurse validates the client's emotions and opens up a channel for further communication. Choice A is incorrect because agreeing with the client's denial is not therapeutic and may hinder acceptance. Choice C is inappropriate as it disregards the client's emotional state and autonomy. Choice D involves the surgeon and is not the nurse's role in addressing the client's emotional needs.

3. Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?

• A. Monitor daily urine output volume
• B. Drink plenty of water whenever thirsty
• C. Use salt tablets for sodium content
• D. Review food labels for sodium content

Correct answer: D

Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.

4. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?

• A. Apply flannel pajamas to provide warmth.
• B. Administer a PRN dose of ibuprofen.
• C. Perform range of motion exercises in a warm tub.
• D. Drape the sheets over the footboard of the bed.

Correct answer: D

Rationale: The correct answer is D. The nurse should first address the immediate comfort concern of the client, which is the weight of the linen on her legs causing severe joint pain. By draping the sheets over the footboard of the bed rather than tucking them under the mattress, the nurse can alleviate the pressure that the client perceives as the source of her pain. This action is a simple and effective way to provide relief and should be the initial step taken by the nurse. Choices A, B, and C do not directly address the client's immediate discomfort caused by the weight of the linen on her legs, making them less appropriate initial actions.

5. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?

• A. Explain the potential respiratory issues associated with morphine use.
• B. Educate the family on assessing the effectiveness of analgesics.
• C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
• D. Provide the client with a schedule for around-the-clock prescribed analgesic use.

Correct answer: D

Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.

Similar Questions