Nursing Elites

1. What is the nurse's priority when caring for a client with a tracheostomy who is showing signs of respiratory distress?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy. When a client with a tracheostomy is experiencing respiratory distress, the priority intervention is to clear the airway by suctioning the tracheostomy to remove secretions that may be obstructing the air passage. Administering a bronchodilator (Choice A) may be considered if bronchospasm is present, but the immediate focus should be on clearing the airway. Notifying the physician (Choice C) is important but should not delay the immediate intervention of suctioning. Increasing the oxygen flow rate (Choice D) may provide temporary relief, but addressing the root cause of the distress by suctioning is the priority.

2. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?

• A. Use a bed exit alarm to notify staff of attempts to leave the bed
• B. Raise all four side rails for safety
• C. Encourage frequent ambulation with assistance
• D. Use restraints to prevent the client from getting out of bed

Correct answer: A

Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.

3. A client with diabetes is being discharged. What is an essential teaching point?

• A. Monitor blood sugar levels once a week
• B. Instruct the client to administer insulin before meals
• C. Teach the client to exercise regularly to maintain glucose control
• D. Administer oral hypoglycemics as needed

Correct answer: B

Rationale: Instructing the client to administer insulin before meals is a crucial teaching point for a client with diabetes. This action ensures proper glucose management by helping to control blood sugar levels. Monitoring blood sugar levels once a week (Choice A) may not be frequent enough to manage diabetes effectively. While regular exercise (Choice C) is beneficial for glucose control, the immediate administration of insulin is more critical at the time of discharge. Administering oral hypoglycemics as needed (Choice D) is inappropriate as it does not address the need for insulin administration for a client being discharged.

4. A client has an NG tube that needs to be irrigated every 8 hours. Which solution should the nurse use to maintain fluid and electrolyte balance?

• A. Tap water
• B. Sterile water
• C. 0.9% sodium chloride
• D. 0.45% sodium chloride

Correct answer: C

Rationale: The correct solution to maintain fluid and electrolyte balance during NG tube irrigation is 0.9% sodium chloride. This solution is isotonic and helps prevent electrolyte imbalances. Using tap water or sterile water can lead to electrolyte disturbances due to their hypotonic nature, while 0.45% sodium chloride is hypotonic and may cause further imbalances in the client's electrolyte levels.

5. A client with asthma and a new prescription for an ipratropium inhaler is being taught by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will rinse my mouth after each use
• B. I should wait 5 minutes before taking a second puff
• C. I should take this medication when I wake up
• D. I should wait 1 minute before taking a second puff

Correct answer: D

Rationale: The correct answer is D because waiting 1 minute between puffs ensures proper absorption of the medication. Choice A is incorrect as rinsing the mouth is not a specific instruction related to using the inhaler. Choice B is incorrect as waiting 5 minutes between puffs is longer than necessary. Choice C is incorrect as the timing of medication administration is not specified in the question.

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