Nursing Elites

1. A client with a tracheostomy develops copious, thick secretions. What is the nurse's priority action?

• A. Increase the client's fluid intake.
• B. Perform tracheal suctioning.
• C. Administer a mucolytic agent.
• D. Increase the humidity of the oxygen source.

Correct answer: D

Rationale: The correct answer is to increase the humidity of the oxygen source. This action helps thin thick secretions, making them easier to clear from the tracheostomy tube. Increasing fluid intake (Choice A) can be beneficial in some cases but addressing humidity is more specific to managing thick secretions in a client with a tracheostomy. Tracheal suctioning (Choice B) should be done after attempting to thin the secretions with increased humidity. Administering a mucolytic agent (Choice C) is a possible intervention but typically comes after addressing humidity and before resorting to suctioning to avoid unnecessary invasiveness.

2. The nurse prepares a discharge plan for an older adult client following cataract extraction. What instructions should the nurse provide?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Irrigate the conjunctiva with saline before applying ointment.
• D. Read without direct lighting for 6 weeks.

Correct answer: A

Rationale: The correct instruction for the nurse to provide after cataract extraction is to advise the client to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure, which should be minimized post-surgery to promote healing and prevent complications. Choices B, C, and D are incorrect because limiting sunlight exposure, irrigating the conjunctiva with saline, and reading without direct lighting are not primary instructions following cataract extraction.

3. A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?

• A. Obtain a urine sample from the bedpan.
• B. Insert an indwelling urinary catheter.
• C. Measure the client's oral temperature.
• D. Remove dressing and assess surgical site.

Correct answer: C

Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.

4. A client with diabetes mellitus reports feeling shaky, dizzy, and sweaty. The nurse checks the client's blood glucose level and it is 55 mg/dL. What is the nurse's next action?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Administer 15 grams of a fast-acting carbohydrate
• D. Recheck the blood glucose level in 15 minutes

Correct answer: C

Rationale: A blood glucose level of 55 mg/dL indicates hypoglycemia, which should be treated with a fast-acting carbohydrate to quickly raise the blood sugar. Administering 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, is the appropriate initial intervention for hypoglycemia. Giving a glucagon injection is reserved for severe cases or when the client is unconscious. Encouraging the client to eat a high-protein snack is not appropriate for treating acute hypoglycemia, as it is a slower-acting form of glucose. Rechecking the blood glucose level is important but should occur after providing immediate treatment to raise the blood sugar level.

5. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?

• A. To observe the type and amount of nasogastric tube drainage
• B. Monitor the client for nausea or other complications
• C. Irrigate the nasogastric tube with the ordered irrigation solution
• D. Perform nostril and mouth care

Correct answer: D

Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.

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