Nursing Elites

1. What action should the nurse take to prevent tracheal tissue damage in a client with a tracheostomy?

• A. Secure the tracheostomy ties firmly.
• B. Change the tracheostomy tube daily.
• C. Use the minimal leak technique when inflating the cuff.
• D. Clean the stoma with hydrogen peroxide.

Correct answer: C

Rationale: To prevent tracheal tissue damage in a client with a tracheostomy, the nurse should use the minimal leak technique when inflating the cuff. This method helps avoid excessive pressure on the tracheal tissue, thereby reducing the risk of damage. Choice A is incorrect because securing the tracheostomy ties too tightly can cause pressure and tissue damage. Choice B is incorrect as changing the tracheostomy tube daily is not necessary unless there is a specific clinical indication. Choice D is incorrect as cleaning the stoma with hydrogen peroxide can irritate the skin and mucous membranes, potentially leading to damage.

2. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?

• A. Is unable to feel sensation in the arms and hands.
• B. Has flaccid upper and lower extremities.
• C. Blood pressure is 110/70 and the apical pulse is 68.
• D. Respirations are shallow, labored, and 14 breaths/minute.

Correct answer: D

Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.

3. A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?

• A. Elevated blood pressure.
• B. Fever and chills.
• C. Increased urine output.
• D. Bradycardia.

Correct answer: B

Rationale: Fever and chills are classic signs of a transfusion reaction. These symptoms indicate that the body is having a response to the transfused blood, possibly due to incompatibility or an immune reaction. Elevated blood pressure (choice A) is not a typical sign of a transfusion reaction. Increased urine output (choice C) and bradycardia (choice D) are also not characteristic signs of a transfusion reaction. It is crucial to recognize symptoms of a transfusion reaction promptly to prevent further complications and ensure appropriate management.

4. What is the primary goal of care for a client experiencing esophageal varices secondary to liver cirrhosis?

• A. Preventing infection
• B. Controlling bleeding
• C. Reducing portal hypertension
• D. Maintaining nutritional status

Correct answer: B

Rationale: The primary goal of care for a client with esophageal varices secondary to liver cirrhosis is to control bleeding. Esophageal varices are fragile, enlarged veins in the esophagus that can rupture and lead to life-threatening bleeding. Controlling bleeding is crucial to prevent severe complications and ensure the client's safety and well-being. Preventing infection (Choice A) is important but not the primary goal in this case. Reducing portal hypertension (Choice C) is a long-term goal that may help prevent variceal bleeding but is not the immediate priority. Maintaining nutritional status (Choice D) is essential for overall health but is secondary to controlling bleeding in this critical situation.

5. A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?

• A. Fruity breath odor.
• B. Blood glucose of 450 mg/dL.
• C. Deep, rapid respirations.
• D. Serum potassium of 5.2 mEq/L.

Correct answer: C

Rationale: The correct answer is C: Deep, rapid respirations (Kussmaul breathing). This is a sign of severe acidosis commonly seen in diabetic ketoacidosis (DKA) and requires immediate intervention. Kussmaul breathing helps to compensate for the metabolic acidosis by blowing off carbon dioxide. Prompt intervention is necessary to prevent further deterioration and potential respiratory failure. Fruity breath odor (Choice A) is a classic sign of DKA but does not require immediate intervention. While a blood glucose level of 450 mg/dL (Choice B) is high, it does not pose an immediate threat to the client's life. Serum potassium of 5.2 mEq/L (Choice D) is slightly elevated but not the most critical finding that requires immediate intervention in this scenario.

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