Nursing Elites

1. How should a healthcare professional manage a patient with a tracheostomy?

• A. Monitor airway patency and provide humidified oxygen
• B. Provide education on tracheostomy care
• C. Suction airway secretions and change tracheostomy ties
• D. Provide a high-protein diet and ensure fluid restriction

Correct answer: A

Rationale: Correct answer: Monitoring airway patency and providing humidified oxygen is crucial in managing a patient with a tracheostomy to ensure proper breathing and oxygenation. Ensuring the airway is clear and providing oxygen support are immediate priorities. Providing education on tracheostomy care (Choice B) is important for long-term management but not the immediate priority. Suctioning airway secretions and changing tracheostomy ties (Choice C) are tasks that may be necessary but do not address the primary concern of maintaining airway patency. Providing a high-protein diet and ensuring fluid restriction (Choice D) are unrelated to the immediate management of a tracheostomy.

2. A nurse is preparing to administer a blood transfusion. What is the first action?

• A. Administer the blood through an IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Ensure the client eats before starting the transfusion

Correct answer: B

Rationale: The correct first action when preparing to administer a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to prevent transfusion reactions and complications. Option A is incorrect because blood transfusions should not be administered through an IV push due to the risk of rapid infusion and adverse reactions. Option C is incorrect because blood should be transfused at room temperature, not body temperature. Option D is incorrect because it is not necessary for the client to eat before a blood transfusion.

3. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

• A. Confused with cold, clammy skin and a pulse of 110
• B. Lethargic with hot, dry skin and rapid, deep respirations
• C. Alert and cooperative with a BP of 130/80 and respirations of 12
• D. Short of breath, with distended neck veins and a bounding pulse of 96

Correct answer: A

Rationale: The correct answer is A. Low blood sugar levels (50 mg/dL) typically cause confusion, cold clammy skin, and an increased pulse (tachycardia). Option A correctly describes the expected symptoms of hypoglycemia, which include confusion due to the brain's inadequate glucose supply, cold and clammy skin due to sympathetic nervous system activation, and an increased pulse (110 bpm) as the body reacts to low blood sugar levels. Options B, C, and D describe symptoms that are not typically associated with hypoglycemia. Lethargy, hot dry skin, rapid deep respirations, normal vital signs, shortness of breath, distended neck veins, and bounding pulse are more indicative of other conditions or normal physiological responses, not hypoglycemia.

4. A nurse is reinforcing teaching about a clear liquid diet. What should the client avoid?

• A. Lemon-lime sports drinks
• B. Orange sherbet
• C. Black coffee
• D. Ginger ale

Correct answer: D

Rationale: The correct answer is D, Ginger ale. A clear liquid diet includes fluids that are see-through and easily digestible. Ginger ale is a carbonated beverage that is allowed on a clear liquid diet. Orange sherbet, choice B, is not suitable for a clear liquid diet as it contains dairy products and solid particles, which are not transparent. Lemon-lime sports drinks, choice A, may contain added colorings or particles that are not allowed on a clear liquid diet. Black coffee, choice C, is also not recommended on a clear liquid diet as it is not a clear liquid and contains substances that may be hard to digest.

5. A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?

• A. History of gastrointestinal bleeding
• B. Prothrombin time of 12 seconds
• C. Platelet count of 180,000/mm³
• D. Creatinine level of 1.0 mg/dL

Correct answer: A

Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.

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