Nursing Elites

1. When suctioning a tracheostomy, which action is most appropriate for the nurse to take?

• A. Use a sterile tube each time and suction for 30 seconds.
• B. Use sterile technique and turn the suction off as the catheter is introduced.
• C. Use clean technique and suction for 10 seconds.
• D. Discard the catheter at the end of every shift.

Correct answer: B

Rationale: When suctioning a tracheostomy, it is crucial to use sterile technique to prevent infections. Turning off the suction as the catheter is introduced is important to avoid trauma and injury to the tracheal walls. This technique helps maintain the integrity of the tracheostomy site and ensures proper care for the patient.

2. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. What respiratory rate should the nurse document?

• A. 14
• B. 16
• C. 17
• D. 28

Correct answer: B

Rationale: The nurse should document a respiratory rate of 16. The second count of eight respirations in a 30-second interval is the most accurate as it was not interrupted by the client coughing. Therefore, this rate reflects the client's typical respiratory pattern and should be documented. Choices A, C, and D are incorrect as they do not consider the interruption caused by the client coughing during the first count, which could have affected the accuracy of the result. The second count of eight respirations provides a more reliable indication of the client's respiratory rate.

3. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?

• A. Ventrogluteal
• B. Outer upper quadrant of the buttock
• C. Two inches below the acromion process
• D. Vastus lateralis

Correct answer: A

Rationale: The ventrogluteal site is the preferred location for administering large volume IM injections to avoid nerve injury. This site is situated away from major nerves and blood vessels, reducing the risk of complications associated with injecting into other areas. The ventrogluteal site allows for deep muscle penetration and is recommended for injections over 2 mL in volume to ensure proper dispersion and absorption of the medication. Choices B, C, and D are incorrect because the outer upper quadrant of the buttock is not the recommended site for large volume injections, two inches below the acromion process is a location for a deltoid injection, and the vastus lateralis is typically used for smaller volume injections.

4. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

• A. Document the client’s temperature fluctuations
• B. Assess for flushed, warm skin consistently
• C. Measure temperature at regular intervals
• D. Use different sites for temperature measurement

Correct answer: C

Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.

5. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?

• A. Americans with Disabilities Act of 1990
• B. ANA Code of Ethics with Interpretative Statements
• C. ANA's Scope and Standards of Nursing Practice
• D. Patient's Bill of Rights of 1990

Correct answer: C

Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric–mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care. Choices A, B, and D are not focused on providing specific guidelines for nursing practice in a mental health services department, making them incorrect options.

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