Nursing Elites

1. A client with a tracheostomy shows signs of respiratory distress. What action should the nurse take immediately?

• A. Increase the suction setting on the ventilator
• B. Administer a bronchodilator
• C. Suction the tracheostomy
• D. Encourage deep breathing exercises

Correct answer: C

Rationale: The correct immediate action for a client with a tracheostomy showing signs of respiratory distress is to suction the tracheostomy. Respiratory distress in this case is often caused by a blockage, which can be quickly relieved by suctioning to clear the airway. Increasing the suction setting on the ventilator (Choice A) may not address the immediate blockage in the tracheostomy. Administering a bronchodilator (Choice B) may help with bronchoconstriction but does not address the potential blockage in the tracheostomy. Encouraging deep breathing exercises (Choice D) may not be effective in relieving the immediate respiratory distress caused by a blocked tracheostomy.

2. What is the first step in preparing a blood transfusion?

• A. Administer the blood via IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Administer diuretics to prevent fluid overload

Correct answer: B

Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.

3. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

• A. The client is experiencing an adverse reaction to rifampin.
• B. The client's seizure disorder is no longer under control.
• C. The client is showing evidence of phenytoin toxicity.
• D. The client is having adverse effects due to combination antimicrobial therapy.

Correct answer: C

Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.

4. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

• A. Place the client in a room close to the nurses' station
• B. Use a bed exit alarm
• C. Encourage family members to stay with the client at all times
• D. Raise all four side rails

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

5. A nurse is caring for a client post-op with a chest tube. What should the nurse check for regularly?

• A. Ensure the chest tube is periodically clamped
• B. Check for air leaks in the tubing
• C. Keep the client in a prone position for chest drainage
• D. Administer diuretics to prevent fluid buildup

Correct answer: B

Rationale: The correct answer is to check for air leaks in the tubing. Air leaks can compromise the function of the chest tube, leading to inadequate drainage and potentially causing complications for the client. Clamping the chest tube periodically is incorrect as it could lead to a buildup of fluid or air in the pleural space. Keeping the client in a prone position is not necessary for chest drainage, as the positioning may vary depending on the specific situation. Administering diuretics may not be directly related to monitoring the chest tube for proper function and is not a routine intervention for chest tube management post-op.

Similar Questions