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 in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. The nurse should report which of the following to the provider after hearing this sound?

• A. Fine crackles
• B. Rhonchi
• C. Wheezing
• D. Stridor

Correct answer: A

Rationale: The correct answer is A: Fine crackles. Fine crackles suggest fluid in the lungs, which could indicate a serious respiratory issue like pulmonary edema. This sound should be reported to the provider for further evaluation and possible intervention. Rhonchi (choice B) are low-pitched wheezing sounds often caused by secretions in the larger airways, wheezing (choice C) is a high-pitched whistling sound usually caused by narrowed airways, and stridor (choice D) is a high-pitched sound heard on inspiration that indicates upper airway obstruction. While these sounds also require attention, fine crackles are more indicative of fluid accumulation in the lungs, making them the priority for reporting in this scenario.

3. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

• A. Soak feet in hot water daily
• B. Use a heating pad on the feet daily
• C. Cut toenails straight across
• D. Massage feet with lotion daily

Correct answer: C

Rationale: The correct answer is C: 'Cut toenails straight across.' This instruction is crucial for clients with diabetes to prevent ingrown toenails and potential foot complications. Soaking feet in hot water daily (Choice A) can lead to skin damage and is not recommended for diabetic individuals. Using a heating pad on the feet daily (Choice B) can cause burns or injuries due to reduced sensation in the feet that often accompanies diabetes. Massaging feet with lotion daily (Choice D) is generally safe but may not address the specific preventive measure of cutting toenails correctly.

4. What is the priority nursing intervention for a patient with chest pain?

• A. Administer nitroglycerin
• B. Assess pain level
• C. Monitor vital signs
• D. Provide oxygen therapy

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.

5. What are the primary causes of respiratory acidosis?

• A. Hypoventilation and lung disease
• B. Hyperventilation and pneumonia
• C. Increased oxygen saturation and tachypnea
• D. Dehydration and hypoxia

Correct answer: A

Rationale: The correct answer is A: Hypoventilation and lung disease. Respiratory acidosis occurs when there is an accumulation of CO2 in the body due to inadequate ventilation. Hypoventilation, which reduces the elimination of CO2, and lung diseases that impair gas exchange are the primary causes. Choice B is incorrect because hyperventilation, not hypoventilation, leads to respiratory alkalosis, not acidosis. Choice C is incorrect because increased oxygen saturation and tachypnea do not directly cause respiratory acidosis. Choice D is incorrect as dehydration and hypoxia do not typically lead to respiratory acidosis.

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