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 is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?

• A. Place an abduction pillow between the client's legs.
• B. Use an abduction pillow between the client's legs.
• C. Encourage the client to cross their legs while sitting.
• D. Encourage the client to sit upright for long periods.

Correct answer: B

Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.

3. The nurse is caring for a client post-surgery with an order to ambulate the client every 2 hours. Which of the following tasks could be safely delegated to an unlicensed assistive personnel (UAP)?

• A. Assessing the client's ability to ambulate safely
• B. Documenting the client's tolerance of ambulation
• C. Assisting the client with ambulation
• D. Evaluating the client's pain level after ambulation

Correct answer: C

Rationale: Assisting with ambulation is a task that can be safely delegated to a UAP as it is a supportive activity that does not require clinical judgment. Choices A, B, and D involve assessments, documentation, and evaluation, which require nursing knowledge and clinical judgment, making them tasks that should be performed by a licensed nurse.

4. The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?

• A. Bananas
• B. Processed meats
• C. Low-fat yogurt
• D. Whole grains

Correct answer: B

Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.

5. The healthcare provider prescribes an IV infusion of isoproterenol in D5W at 300 mcg/hour. How many ml/hour should the nurse set the pump to?

• A. 100 ml/hour
• B. 75 ml/hour
• C. 60 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct infusion rate, convert 300 mcg/hour to mg/hour (300 mcg = 0.3 mg). Since the IV solution is 1 mg in 250 ml, the rate is calculated as 0.3 mg/hour = 75 ml/hour. Therefore, the nurse should set the pump to 75 ml/hour. Choice A (100 ml/hour) is incorrect as it does not reflect the accurate calculation. Choice C (60 ml/hour) is incorrect as it is lower than the correct rate. Choice D (125 ml/hour) is incorrect as it is higher than the correct rate.

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