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. When receiving change-of-shift report for a group of clients, which time-management strategy should the nurse plan to implement?

• A. Prepare a priority list of client needs for the shift
• B. Complete less time-consuming tasks first
• C. Handle urgent client needs at the end of the shift
• D. Work on each client as they are seen

Correct answer: A

Rationale: Preparing a priority list of client needs for the shift is the most effective time-management strategy for a nurse receiving change-of-shift report. This approach helps the nurse identify and address the most urgent client needs first, ensuring efficient use of time. Choice B is incorrect because focusing on less time-consuming tasks first may result in crucial tasks being delayed. Choice C is incorrect as urgent client needs should be handled promptly, not postponed until the end of the shift. Choice D is inefficient as it does not prioritize tasks based on urgency, potentially leading to delays in addressing critical client needs.

3. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?

• A. Serum albumin level of 3 g/dL
• B. HDL level of 90 mg/dL
• C. Norton scale score of 18
• D. Braden scale score of 20

Correct answer: A

Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, which is commonly associated with pressure ulcers. This finding suggests that the client may be at risk for developing or already has a pressure ulcer due to malnutrition. High-density lipoprotein (HDL) level of 90 mg/dL (Choice B) is not directly related to pressure ulcers. The Norton scale (Choice C) is used to assess a client's risk of developing pressure ulcers, not as a finding in a client with an existing pressure ulcer. The Braden scale (Choice D) is also a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer.

4. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin A1c of 6%
• B. Fasting blood glucose of 90 mg/dL
• C. Blood glucose of 200 mg/dL
• D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

5. How should a healthcare professional manage a patient with an indwelling urinary catheter?

• A. Monitor urine output and ensure proper drainage
• B. Administer antibiotics and change the catheter regularly
• C. Monitor for signs of infection and provide catheter care
• D. Provide high-sodium diet and monitor hydration

Correct answer: A

Rationale: Monitoring urine output and ensuring proper catheter drainage are crucial aspects of managing a patient with an indwelling urinary catheter. This helps in assessing the patient's renal function, fluid balance, and the patency of the catheter. Administering antibiotics and changing the catheter regularly (Choice B) may not be necessary unless there is an infection present. While monitoring for signs of infection and providing catheter care (Choice C) are important, the primary focus should be on urine output and drainage. Providing a high-sodium diet and monitoring hydration (Choice D) are not directly related to managing an indwelling urinary catheter.

Similar Questions