Nursing Elites

1. Which of the following is an early indication that a tracheostomy client requires suctioning?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased respiratory rate

Correct answer: B

Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.

2. In the emergency department, a nurse is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

• A. Below-the-knee amputation.
• B. 10 cm (4 in) laceration.
• C. Fractured tibia.
• D. 95% full-thickness body burn.

Correct answer: A

Rationale: A below-the-knee amputation requires immediate attention due to the risk of hemorrhage and shock, making it the highest priority. This type of injury can lead to significant blood loss and impaired perfusion, which can be life-threatening if not addressed promptly. While a 10 cm laceration, a fractured tibia, and a 95% full-thickness body burn are serious injuries requiring urgent care, they do not pose the same immediate threat to life as a below-the-knee amputation. The laceration may require suturing to control bleeding and prevent infection, the fractured tibia needs stabilization to prevent further damage and pain, and the burn necessitates immediate management to prevent complications, but they are not as acutely life-threatening as the amputation.

3. A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?

• A. Use abdominal breathing during physical activity
• B. Inhale quickly and deeply through the nose
• C. Use pursed-lip breathing during physical activity
• D. Breathe quickly and deeply during exercise

Correct answer: C

Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.

4. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

5. A client who is to undergo surgery for a hip fracture is being taught by a nurse about postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will ask for pain medication only if the pain becomes unbearable.
• B. I will ask the nurse to increase my medication if the pain doesn't subside.
• C. I will wait until the pain is severe before taking my medication.
• D. I will take my medication at regular intervals to stay ahead of the pain.

Correct answer: D

Rationale: The correct answer is D because taking pain medication at regular intervals helps maintain consistent pain control after surgery. Option A is incorrect because waiting for the pain to become unbearable can lead to inadequate pain management. Option B is incorrect as it suggests increasing medication without a schedule. Option C is incorrect because waiting for the pain to be severe before taking medication is not proactive pain management.

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