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 needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

• A. I had a bowel movement, but I was able to save the urine.
• B. I have a specimen in the bathroom from about 30 minutes ago.
• C. I flushed what I urinated at 7 am and have saved the rest since.
• D. I drink a lot, so I will fill up the bottle and complete the test quickly.

Correct answer: C

Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.

3. How should a healthcare professional assess a patient with hyperkalemia?

• A. Monitor ECG and administer insulin
• B. Monitor blood glucose levels and provide fluids
• C. Monitor for muscle weakness and administer calcium gluconate
• D. Monitor electrolyte levels and provide potassium supplements

Correct answer: A

Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels. Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia. Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia. Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.

4. What is the priority intervention for sepsis?

• A. Administer IV antibiotics
• B. Monitor blood pressure
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: In the management of sepsis, prompt intervention is crucial. Administering IV antibiotics is essential to target the underlying infection. Monitoring blood pressure helps assess the patient's hemodynamic status. Administering fluids is vital to maintain adequate perfusion. Therefore, all the options are integral components of the initial management of sepsis, making 'All of the above' the correct answer. Choosing any single intervention over the others may delay optimal care and compromise patient outcomes.

5. A nurse is caring for a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the first hour after surgery.
• B. Constant bubbling in the water seal chamber.
• C. Tidaling in the water seal chamber.
• D. Client report of pain at the chest tube insertion site.

Correct answer: B

Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.

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