Nursing Elites

1. What is a priority when providing care for a patient with a newly inserted tracheostomy?

• A. Keeping the tracheostomy tube clean and dry
• B. Providing regular oral hygiene
• C. Monitoring for signs of infection and ensuring a patent airway
• D. Encouraging the patient to cough and deep breathe

Correct answer: C

Rationale: When caring for a patient with a newly inserted tracheostomy, the priority is to monitor for signs of infection and ensure a patent airway. This is crucial to prevent complications such as airway obstruction or infection. While keeping the tracheostomy tube clean and dry is important for overall care, it is not the highest priority when compared to ensuring a patent airway. Providing regular oral hygiene is essential for the patient's comfort but takes a secondary role to maintaining airway patency. Encouraging the patient to cough and deep breathe may be beneficial but is not as critical as monitoring for infection and keeping the airway clear.

2. A nurse is assisting in the admission of a young adult female Korean exchange student with acute abdominal pain. When asked about her sexual activity, she looks away. What should the nurse do?

• A. Omit this question from the assessment form
• B. Ask her if she would like an interpreter present to assist with communication
• C. Reword the question to ensure the client's understanding
• D. Watch the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to a different question can help gauge her comfort level and understanding, which is essential in culturally sensitive care. By watching her response to a different question, the nurse can assess if the discomfort is related to the specific question or a broader issue. Omitting the question may result in missing crucial information. Asking about an interpreter assumes that the language barrier is the only issue, which may not be the case. Rewording the question may not address the underlying discomfort and could still lead to misinterpretation.

3. What is the most common cause of acute pancreatitis?

• A. Gallstones
• B. Alcohol abuse
• C. Hypertriglyceridemia
• D. Infection

Correct answer: A

Rationale: The correct answer is A: Gallstones. Gallstones are the most common cause of acute pancreatitis as they obstruct the pancreatic duct, leading to inflammation. While alcohol abuse (Choice B) can also cause pancreatitis, gallstones are more prevalent. Hypertriglyceridemia (Choice C) is a less common cause of acute pancreatitis compared to gallstones. Infection (Choice D) is not a primary cause of acute pancreatitis; gallstones are the leading etiology.

4. You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?

• A. 10
• B. 8
• C. 7
• D. 9

Correct answer: D

Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.

5. Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?

• A. How much exercise did the child have today?
• B. Did the child perform a finger stick?
• C. When did the child last urinate?
• D. Has the child eaten recently?

Correct answer: B

Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.

Similar Questions