Nursing Elites

1. Which of the following is an early indicator that a client with a tracheostomy may require suctioning?

• A. Decreased respiratory rate
• B. Irritability
• C. Bradycardia
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early indicator that suctioning is necessary for a client with a tracheostomy. Irritability can signal discomfort or difficulty breathing, which may be due to the need for suctioning to clear the airway. Decreased respiratory rate, bradycardia, and decreased oxygen saturation are not typically early indicators that suctioning is needed in a client with a tracheostomy. These symptoms may occur later if the airway is not cleared promptly.

2. What is the most effective way to prevent the spread of infection in a healthcare setting?

• A. Hand hygiene
• B. Wearing personal protective equipment
• C. Sterilizing equipment
• D. Isolating infected patients

Correct answer: A

Rationale: Hand hygiene is considered the most effective method to prevent the spread of infection in a healthcare setting. Proper hand hygiene, including washing hands with soap and water or using hand sanitizer, is crucial in reducing the transmission of pathogens from one person to another. While wearing personal protective equipment, sterilizing equipment, and isolating infected patients are also important infection control measures, they are not as universally effective as hand hygiene in preventing the spread of infections. Personal protective equipment can prevent contact with infectious materials, sterilizing equipment reduces the risk of contamination, and isolating infected patients helps prevent the spread of specific infections, but they are more targeted approaches compared to the broad and essential practice of hand hygiene.

3. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

• A. Increase in frequency of swallowing.
• B. Moderate sanguineous drainage on the drip pad.
• C. Bruising to the face.
• D. Absent gag reflex.

Correct answer: A

Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.

4. How should a healthcare provider assess and manage a patient with a potential myocardial infarction (MI)?

• A. Assess symptoms, monitor vital signs, order ECG
• B. Administer medications and monitor for pain
• C. Administer thrombolytics and oxygen therapy
• D. Educate patient on lifestyle changes

Correct answer: A

Rationale: Correct Answer: A. When assessing a patient with a potential myocardial infarction, it is crucial to assess symptoms, monitor vital signs like blood pressure and heart rate, and order an electrocardiogram (ECG) to evaluate for cardiac abnormalities. Choice B is incorrect because administering medications should be based on the findings of the assessment and diagnostic tests, not administered indiscriminately. Choice C is incorrect because the administration of thrombolytics and oxygen therapy should be based on specific criteria and should be done in a controlled setting. Choice D is incorrect as educating the patient on lifestyle changes is important for prevention but is not the immediate priority when managing a potential myocardial infarction.

5. What is the appropriate intervention for a patient experiencing hypovolemic shock?

• A. Administer IV fluids
• B. Monitor blood pressure
• C. Place the patient in Trendelenburg position
• D. Administer oxygen

Correct answer: A

Rationale: The correct intervention for a patient experiencing hypovolemic shock is to administer IV fluids. In hypovolemic shock, there is a significant loss of circulating blood volume leading to inadequate perfusion to tissues. Administering IV fluids is crucial to restore blood volume and improve tissue perfusion. Monitoring blood pressure (choice B) is important but not the primary intervention in hypovolemic shock. Placing the patient in Trendelenburg position (choice C) can worsen outcomes by increasing intracranial pressure and is no longer recommended. Administering oxygen (choice D) is beneficial for many conditions but does not address the underlying issue of inadequate circulating blood volume in hypovolemic shock.

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