Nursing Elites

1. The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?

• A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
• B. Administer 15 mL of sterile fluid into the tube prior to suctioning
• C. Suction for no longer than 30 seconds at a time
• D. Wait 30 seconds after suctioning before attempting again

Correct answer: A

Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.

2. The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

• A. Hemoglobin
• B. Temperature
• C. Activity level
• D. Albumin level

Correct answer: D

Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. In this case, monitoring the albumin level is crucial to assess the patient's fluid balance and potential for edema. While hemoglobin, temperature, and activity level are important parameters to monitor in a patient's assessment, they are not directly associated with the patient's current symptoms of toxic hepatitis and edema development. Therefore, the correct choice is the albumin level.

3. A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

• A. Back Pain
• B. Fever and Chills
• C. Risk for Bleeding
• D. Dizziness

Correct answer: C

Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.

4. A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

• A. Has increased airway obstruction
• B. Has improved airway obstruction
• C. Needs to be suctioned
• D. Exhibits hyperventilation

Correct answer: B

Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.

5. Which of these clients is likely to receive sublingual morphine?

• A. A 75-year-old woman in a hospice program
• B. A 40-year-old man who just had throat surgery
• C. A 20-year-old woman with trigeminal neuralgia
• D. A 60-year-old man who has a painful incision

Correct answer: A

Rationale: The correct answer is a 75-year-old woman in a hospice program. Sublingual morphine is commonly used in hospice care because patients may have difficulty swallowing, and intravenous access can be uncomfortable and not ideal for palliative care. Choice B, a 40-year-old man who just had throat surgery, is less likely to receive sublingual morphine as he may be able to swallow, and other pain management options may be more suitable. Choice C, a 20-year-old woman with trigeminal neuralgia, would typically require specific medications targeting neuropathic pain rather than sublingual morphine. Choice D, a 60-year-old man with a painful incision, may benefit from localized pain relief or other systemic pain management options, but sublingual morphine is not usually the first choice for this type of pain.

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