Nursing Elites

1. A client with a tracheostomy is exhibiting signs of respiratory distress. What should the nurse do first?

• A. Notify the healthcare provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the priority action is to suction the tracheostomy to clear the airway and improve breathing. This helps remove secretions or blockages that may be causing the distress. Notifying the healthcare provider (Choice A) can be done after ensuring immediate airway clearance. Administering a bronchodilator (Choice C) would not address the primary issue of airway clearance in a tracheostomy patient. Increasing the oxygen flow rate (Choice D) may be necessary but should come after ensuring the airway is clear.

2. A nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

• A. Urine output of 20 mL/hr.
• B. Temperature of 36.5°C (97.7°F).
• C. Sanguineous drainage on the surgical dressing.
• D. WBC count of 9,000/mm3.

Correct answer: A

Rationale: The correct answer is A: Urine output of 20 mL/hr. A urine output less than 30 mL/hr can indicate decreased renal perfusion, potentially due to hypovolemia or other issues, and should be reported to the provider. B: A temperature of 36.5°C (97.7°F) falls within the normal range and does not require immediate reporting. C: Sanguineous drainage on the surgical dressing is expected in the early postoperative period and should be monitored but does not need immediate reporting unless excessive. D: A WBC count of 9,000/mm3 is within the normal range and does not indicate an immediate concern.

3. A healthcare professional is reviewing the medical record of a client who underwent surgery for a hip fracture. Which of the following findings should the healthcare professional report to the provider?

• A. Clear lung sounds
• B. Fever
• C. Pain in the operative leg
• D. Capillary refill of 2 seconds

Correct answer: B

Rationale: The correct answer is B: Fever. Fever in a postoperative client can indicate an infection, which is a serious complication and should be reported immediately to the provider for further evaluation and management. Clear lung sounds (Choice A) are a positive finding indicating normal respiratory function. Pain in the operative leg (Choice C) is expected postoperatively and should be managed with appropriate pain relief measures. Capillary refill of 2 seconds (Choice D) is within the normal range (less than 3 seconds) and is not a concerning finding postoperatively.

4. A client undergoing surgery is being taught about the use of a patient-controlled analgesia (PCA) pump by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will ask my spouse to push the button when I am sleeping
• B. I will use the PCA pump to keep me comfortable during the night
• C. I will ask the nurse to increase the dosage if I still feel pain
• D. I will press the button for medication as soon as I feel pain

Correct answer: D

Rationale: The correct answer is D because clients should press the button on the PCA pump when they feel pain to receive controlled doses of medication. Option A is incorrect as the client should be the one to self-administer the medication through the PCA pump. Option B is incorrect as the primary purpose of the PCA pump is to manage pain, not to keep the client comfortable. Option C is incorrect because the client should not adjust the dosage themselves; instead, they should communicate any pain concerns to the healthcare provider.

5. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect?

• A. Polyuria.
• B. Dehydration.
• C. Hyponatremia.
• D. Hyperglycemia.

Correct answer: C

Rationale: The correct answer is C: Hyponatremia. In SIADH, there is excessive release of antidiuretic hormone, causing water retention and dilutional hyponatremia. Polyuria (choice A) is increased urination, which is not a typical finding in SIADH. Dehydration (choice B) is the loss of body fluids, which is opposite to the fluid retention seen in SIADH. Hyperglycemia (choice D) is elevated blood sugar levels and is not directly related to SIADH.

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