Nursing Elites

1. The healthcare provider is assessing a client with Raynaud's phenomenon. Which finding should the healthcare provider expect?

• A. Thickened and hardened skin.
• B. Painless ulcers on the fingertips.
• C. Episodes of cyanosis and pallor in the fingers.
• D. Red, scaly patches on the hands.

Correct answer: C

Rationale: Raynaud's phenomenon is characterized by vasospasm, leading to episodes of cyanosis (bluish discoloration) and pallor (pale color) in the fingers or toes, often triggered by cold temperatures or stress. This occurs due to the reduced blood flow during vasospastic episodes, causing the discoloration. Choices A, B, and D are incorrect findings associated with other conditions and are not typical of Raynaud's phenomenon.

2. The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?

• A. Hyperpigmentation of the skin.
• B. Hypotension.
• C. Moon face and buffalo hump.
• D. Weight loss.

Correct answer: C

Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excess production of corticosteroids leads to redistribution of fat, particularly in the face (moon face) and between the shoulders (buffalo hump). Hyperpigmentation of the skin is actually associated with Addison's disease, not Cushing's syndrome (choice A). Hypotension is not a typical finding in Cushing's syndrome; instead, hypertension is more commonly seen due to the effects of excess cortisol (choice B). Weight gain, rather than weight loss, is a common symptom of Cushing's syndrome due to the metabolic disturbances caused by excess cortisol (choice D).

3. The client has a nasogastric (NG) tube and is receiving enteral feedings. What intervention should the nurse implement to prevent complications associated with the NG tube?

• A. Flush the NG tube with water before and after feedings.
• B. Check gastric residual volume every 6 hours.
• C. Keep the head of the bed elevated at 30 degrees.
• D. Replace the NG tube every 24 hours.

Correct answer: C

Rationale: Keeping the head of the bed elevated at 30 degrees is crucial in preventing aspiration, a common complication associated with nasogastric (NG) tubes and enteral feedings. This position helps reduce the risk of reflux and aspiration of gastric contents into the lungs, promoting client safety and preventing respiratory complications. Flushing the NG tube with water before and after feedings (Choice A) is not the primary intervention to prevent complications. Checking gastric residual volume every 6 hours (Choice B) is important but not directly related to preventing complications associated with the NG tube. Replacing the NG tube every 24 hours (Choice D) is not a standard practice and is not necessary to prevent complications if the tube is functioning properly.

4. A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?

• A. Heart rate of 110 beats per minute.
• B. Blood pressure of 90/60 mm Hg.
• C. Urine output of 20 ml/hour.
• D. Dry mucous membranes.

Correct answer: C

Rationale: A urine output of 20 ml/hour indicates severe dehydration and impaired renal function. This finding suggests a critical state where the kidneys are conserving water, leading to reduced urine output. Immediate intervention is required to restore fluid balance and prevent further complications associated with severe dehydration. Choice A, a heart rate of 110 beats per minute, may indicate dehydration but is not as severe as the critically low urine output. Choice B, a blood pressure of 90/60 mm Hg, can be seen in dehydration but is not as concerning as the extremely low urine output. Choice D, dry mucous membranes, is a common sign of dehydration but does not require immediate intervention compared to the severely reduced urine output.

5. The healthcare provider is providing care to a client with a tracheostomy. Which action should the healthcare provider take to prevent tracheostomy complications?

• A. Use sterile technique when performing tracheostomy care.
• B. Suction the tracheostomy tube every hour.
• C. Keep the tracheostomy tube cuff inflated at all times.
• D. Change the tracheostomy ties daily.

Correct answer: A

Rationale: Using sterile technique when performing tracheostomy care is essential to prevent infections and other complications. Proper sterile technique helps reduce the risk of introducing harmful bacteria into the tracheostomy site, which can lead to infections and other serious issues. By maintaining a sterile environment during tracheostomy care, the healthcare provider can promote healing and prevent potential complications.

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