Nursing Elites

1. Which of the following is an early sign that suctioning is required for a client with a tracheostomy?

• A. Bradycardia
• B. Irritability
• C. Confusion
• D. Hypotension

Correct answer: B

Rationale: Irritability is an early sign that suctioning is necessary to clear the airway in a client with a tracheostomy. When secretions build up in the tracheostomy tube, the client may become irritable due to the discomfort and the compromised airway. Bradycardia, confusion, and hypotension are not typically early signs that suctioning is required. Bradycardia may occur if the airway becomes severely compromised, confusion may be a late sign of hypoxia, and hypotension is not directly related to the need for suctioning in a client with a tracheostomy.

2. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.

3. A client with moderate anxiety disorder is being taught stress management techniques by a nurse. Which response by the client indicates an understanding of the teaching?

• A. I will take a walk to reduce my anxiety
• B. I will imagine myself in a calm place when I can't concentrate
• C. I will meditate every other week
• D. I will cut back on my caffeine intake

Correct answer: B

Rationale: The correct answer is B because imagining oneself in a calm place is a relaxation technique that helps reduce anxiety. Walking, meditating every other week, or cutting back on caffeine intake may have their benefits, but they are not as directly related to the immediate management of anxiety as the visualization technique described in option B.

4. A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will avoid feeding my baby for 12 hours
• B. I will apply diaper cream during each diaper change
• C. I will give my baby water between feedings
• D. I will apply warm compresses for my baby's comfort

Correct answer: B

Rationale: The correct answer is B. Applying diaper cream during each diaper change is important to prevent skin breakdown in infants with rotavirus. Rotavirus can cause diarrhea, which can lead to skin irritation. Avoiding feeding the baby for 12 hours (choice A) can lead to dehydration and is not appropriate. Giving water between feedings (choice C) can further contribute to dehydration. Applying warm compresses (choice D) may provide comfort but does not address the specific issue of preventing skin breakdown associated with rotavirus.

5. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

• A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
• B. Nail polish should not be used near a client who is receiving oxygen
• C. A 'No Smoking' sign should be placed on the front door
• D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

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