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. A client receiving chemotherapy reports nausea and vomiting. What is the nurse's priority intervention?

• A. Administer antiemetic medication before meals
• B. Encourage the client to eat small, frequent meals
• C. Instruct the client to avoid eating during treatment
• D. Provide the client with cold beverages during meals

Correct answer: A

Rationale: The correct answer is A: Administer antiemetic medication before meals. When a client receiving chemotherapy reports nausea and vomiting, administering antiemetic medication before meals is a priority intervention to help reduce nausea associated with chemotherapy. This proactive approach can prevent or minimize the symptoms, improving the client's quality of life during treatment. Choice B is incorrect because while encouraging the client to eat small, frequent meals can be helpful, administering antiemetic medication is the priority to address the immediate symptoms. Choice C is incorrect as avoiding eating during treatment may lead to nutritional deficits, and choice D is incorrect because providing cold beverages during meals may not effectively address the nausea and vomiting symptoms.

3. How should a healthcare professional manage a patient with fluid overload?

• A. Restrict fluids and administer diuretics
• B. Increase fluid intake and provide oral diuretics
• C. Administer antibiotics and monitor weight
• D. Monitor weight and provide a low-sodium diet

Correct answer: A

Rationale: Corrected Question: When managing a patient with fluid overload, the appropriate approach involves restricting fluids and administering diuretics. This strategy helps remove excess fluid from the body and prevent complications associated with fluid overload. Choice B suggesting increasing fluid intake is incorrect as it would worsen the condition. Choice C, administering antibiotics, is unrelated to managing fluid overload. Choice D, monitoring weight and providing a low-sodium diet, is helpful but not as effective as fluid restriction and diuretics in managing fluid overload.

4. How should a healthcare professional monitor a patient receiving IV potassium?

• A. Monitor ECG for dysrhythmias
• B. Monitor urine output
• C. Monitor serum potassium levels
• D. All of the above

Correct answer: D

Rationale: When a patient is receiving IV potassium, it is crucial to monitor various parameters to ensure patient safety. Monitoring the ECG helps in identifying any potential dysrhythmias that may occur due to potassium imbalances. Monitoring urine output is important as potassium levels can affect renal function. Monitoring serum potassium levels is essential to assess the effectiveness of the IV potassium therapy. Therefore, all the options - monitoring ECG for dysrhythmias, urine output, and serum potassium levels - are necessary when administering IV potassium, making 'All of the above' the correct answer. Choices A, B, and C are not individually sufficient as they each address different aspects of patient monitoring when receiving IV potassium.

5. A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. A fasting blood glucose of 90 mg/dL
• B. A blood glucose level of 200 mg/dL
• C. A hemoglobin A1c of 6%
• D. A fasting blood glucose of 100 mg/dL

Correct answer: B

Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.

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