Nursing Elites

1. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

• A. Providing humidified oxygen
• B. Ensuring the tracheostomy ties are secure
• C. Suctioning the tracheostomy tube as needed
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

2. What is the most common sign of a localized infection?

• A. Fever
• B. Elevated white blood cell count
• C. Redness, warmth, and swelling at the site of infection
• D. Chills and shivering

Correct answer: C

Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.

3. A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?

• A. Hold a pillow against the chest while coughing (splinting).
• B. Take shallow breaths to avoid pain.
• C. Increase the dose of pain medication.
• D. Avoid deep breathing exercises.

Correct answer: A

Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.

4. Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

• A. I don't have any use for those who say the disease is going to win
• B. I've found the support I need from my faith and family
• C. I think I've had this disease for a long time, but the doctor did not find it
• D. I understand that this is a disease that occurs mostly in older men

Correct answer: B

Rationale: The correct answer is B because finding support in faith and family is a common way for individuals to cope with serious illnesses and come to terms with their prognosis. This statement indicates that the client has found a source of strength and comfort to deal with their situation. Choice A reflects defiance rather than acceptance. Choice C suggests denial or disbelief in the diagnosis. Choice D shows factual knowledge about the disease but does not necessarily indicate acceptance of the prognosis.

5. Which of the following is a primary intervention for a patient experiencing hypoglycemia?

• A. Administering insulin
• B. Providing a complex carbohydrate meal
• C. Giving 15 grams of a fast-acting carbohydrate, like glucose tablets
• D. Encouraging the patient to exercise

Correct answer: C

Rationale: Giving 15 grams of a fast-acting carbohydrate, such as glucose tablets, is the primary intervention for hypoglycemia. This rapid-acting carbohydrate helps quickly raise blood sugar levels, providing immediate relief to the patient. Administering insulin (Choice A) would further lower blood sugar levels, exacerbating the hypoglycemia. Providing a complex carbohydrate meal (Choice B) would not act quickly enough to address the immediate low blood sugar issue. Encouraging the patient to exercise (Choice D) is inappropriate during hypoglycemia as it can further deplete glucose levels.

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