Nursing Elites

1. When caring for a client with a tracheostomy, which action should the nurse take first when performing tracheostomy care?

• A. Remove the inner cannula.
• B. Clean the stoma with normal saline.
• C. Change the tracheostomy ties.
• D. Suction the tracheostomy.

Correct answer: D

Rationale: Suctioning the tracheostomy is the priority action because it ensures a patent airway before proceeding with any other tracheostomy care interventions. This step helps clear secretions and maintain airway patency, which is crucial for the client's respiratory status. Removing the inner cannula, cleaning the stoma, or changing the tracheostomy ties can follow once the airway is clear. Therefore, options A, B, and C are secondary actions compared to suctioning the tracheostomy.

2. A public health nurse is planning a campaign to increase immunization rates among children in a low-income community. Which intervention should the nurse prioritize?

• A. Provide free immunizations at local schools
• B. Create educational materials about vaccine safety
• C. Organize a community forum to discuss immunization concerns
• D. Partner with local media to promote the importance of vaccines

Correct answer: A

Rationale: The correct answer is A: Provide free immunizations at local schools. This intervention directly addresses financial barriers and increases accessibility for families in low-income communities. By offering free immunizations at local schools, the nurse can ensure that more children receive the necessary vaccines without worrying about the cost. Choice B, creating educational materials, may be helpful but may not directly address the financial barriers that low-income families face. Choice C, organizing a community forum, can be beneficial for addressing concerns but may not result in immediate action to increase immunization rates. Choice D, partnering with local media, can help raise awareness but may not directly provide the solution of making immunizations more accessible by removing financial barriers.

3. A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?

• A. Wear a gown and gloves.
• B. Have the client wear a mask.
• C. Perform hand hygiene.
• D. Assign the client to a negative air-flow room.

Correct answer: D

Rationale: The correct answer is to assign the client to a negative air-flow room (Choice D). Active tuberculosis requires implementation of airborne precautions, including isolating the client in a negative pressure air-flow room to prevent the spread of the infection to others. Choice A (Wear a gown and gloves) is important for standard precautions but does not address the specific airborne precautions needed for tuberculosis. Choice B (Have the client wear a mask) may help reduce the spread of respiratory droplets but does not provide adequate protection for healthcare workers or other patients. Choice C (Perform hand hygiene) is essential for infection control but is not the most critical action when dealing with an airborne infection like tuberculosis.

4. The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?

• A. Blood pressure of 160/90 mm Hg.
• B. Blood glucose level of 180 mg/dL.
• C. Difficulty speaking.
• D. Temperature of 99.8°F (37.7°C).

Correct answer: C

Rationale: Difficulty speaking is a classic symptom of a stroke, indicating a potential blockage of blood flow to the brain. Immediate intervention is crucial to minimize brain damage. While an elevated blood pressure (Choice A) may need management, it is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) falls within the normal range and is not a critical finding in this context.

5. The healthcare provider provides teaching to a group of evacuees in a mass casualty center after a natural flooding disaster. Which information should the healthcare provider include in the teaching plan? (select one that does not apply.)

• A. wash all fruits and vegetables thoroughly in running tap water
• B. identify all sexual contacts since the evacuation process
• C. take all doses of prophylactic prescriptions for diarrhea
• D. clean hands using soap, clean water, or waterless antibacterial solutions

Correct answer: B

Rationale: In the aftermath of a flooding disaster, educating evacuees on proper hygiene practices like washing fruits and vegetables, taking prophylactic prescriptions, and practicing hand hygiene is crucial to prevent the spread of diseases. Option B, identifying sexual contacts, is not relevant to preventing post-disaster health risks and should not be included in the teaching plan.

Similar Questions