Nursing Elites

1. 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.

2. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

• A. Call the radiology department
• B. Reinsert the implant into the vagina
• C. Apply double gloves to retrieve the implant for disposal
• D. Place the implant in a lead container using long-handled forceps

Correct answer: D

Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.

3. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling very tired. Which nursing intervention is most important for the nurse to implement?

• A. Measure vital signs
• B. Auscultate breath sounds
• C. Palpate the abdomen
• D. Observe the skin for bruising

Correct answer: A

Rationale: Discontinuing prednisone abruptly can lead to adrenal insufficiency, which may result in symptoms such as fatigue. Monitoring vital signs is crucial in this situation to assess for potential complications like hypotension, which can be a sign of adrenal insufficiency. Auscultating breath sounds (choice B) is important but not the priority when considering the risk of adrenal insufficiency. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of abruptly stopping prednisone.

4. A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?

• A. Tissue sloughing upon extravasation
• B. Elevated blood pressure and heart rate
• C. Tinnitus and vertigo
• D. Erythema of the face, neck, and chest

Correct answer: C

Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.

5. A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.)

• A. Increased heart rate
• B. Visual disturbances
• C. Presence of uremic frost
• D. Decreased mentation

Correct answer: A

Rationale: The correct signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) include increased heart rate, visual disturbances, and decreased mentation. These symptoms are often associated with HHNS due to the high blood glucose levels. Uremic frost, a sign of advanced kidney disease, is not typically associated with HHNS. Therefore, choices B and D are incorrect. However, choice C, 'Presence of uremic frost,' is incorrect as it is not typically associated with HHNS.

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