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. What are the nursing interventions for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Administer antiplatelet therapy
• C. Check for signs of DVT and provide anticoagulation
• D. Administer aspirin and monitor for bleeding

Correct answer: A

Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.

3. 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.

4. A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?

• A. Walk for at least 30 minutes each day
• B. Avoid sunlight exposure
• C. Take vitamin B12 supplements
• D. Increase calcium intake to 1,500 mg per day

Correct answer: D

Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.

5. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.

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