Nursing Elites

1. While caring for a client with a new tracheostomy, the nurse notices that the client is attempting to speak but is unable to. What should the nurse explain to the client regarding their inability to speak?

• A. Speaking is not possible because the tracheostomy tube blocks the vocal cords.
• B. The tracheostomy tube prevents air from reaching the vocal cords, making speech difficult.
• C. The client will regain the ability to speak once the tracheostomy tube is removed.
• D. The tracheostomy tube must be replaced with a speaking valve for the client to speak.

Correct answer: B

Rationale: The correct answer is B. The tracheostomy tube bypasses the vocal cords, preventing air from reaching them, which is necessary for speech. This makes speaking difficult but not impossible. Removing the tracheostomy tube does not automatically restore the ability to speak (choice C). While a speaking valve can be added later to allow speech, initially, the tracheostomy tube itself hinders air from reaching the vocal cords, making speech difficult (choice D is incorrect). Choice A is incorrect as the tracheostomy tube does not block the vocal cords directly; instead, it prevents air from reaching them.

2. The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement?

• A. Obtain further data about the client's activity intolerance to position changes
• B. Advise the UAP to allow the client to rest before completing the bath
• C. Direct the UAP to obtain vital signs and a pulse oximetry reading
• D. Notify the healthcare provider about the client's episode of SOB

Correct answer: B

Rationale: Advising the UAP to allow the client to rest before completing the bath is the most appropriate action to take. This helps manage the shortness of breath (SOB) experienced by the client and prevents further stress. By giving the client time to rest, the PN ensures the client's comfort and safety during care activities. The other options are not the most immediate or appropriate actions in this scenario: obtaining further data about activity intolerance (choice A) may delay addressing the current issue, obtaining vital signs and pulse oximetry (choice C) is important but not as immediate as allowing the client to rest, and notifying the healthcare provider (choice D) is premature before trying a simple intervention like allowing the client to rest.

3. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

4. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

• A. Glucose should be taken if I have a fruity breath odor.
• B. Glucose should be taken if I am urinating more than usual.
• C. Glucose should be taken if I have blurred vision.
• D. Glucose should be taken if I develop shakiness.

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

5. After a hip replacement surgery, a client is instructed to use an abduction pillow while in bed. What is the primary purpose of this device?

• A. To reduce the risk of blood clots.
• B. To prevent hip dislocation.
• C. To improve circulation in the legs.
• D. To alleviate pain and discomfort.

Correct answer: B

Rationale: The primary purpose of using an abduction pillow after hip replacement surgery is to prevent hip dislocation. The abduction pillow keeps the legs separated, which reduces the risk of hip dislocation by preventing excessive internal rotation and adduction of the hip joint. Choices A, C, and D are incorrect as the main goal of using the abduction pillow is to maintain proper positioning and stability of the hip joint to prevent dislocation, rather than addressing blood clots, circulation, or pain relief.

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