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 key management strategy for diabetic ketoacidosis (DKA)?

• A. Administer insulin
• B. Monitor blood glucose
• C. Administer IV fluids
• D. All of the above

Correct answer: D

Rationale: The key management strategy for diabetic ketoacidosis (DKA) involves a comprehensive approach that includes administering insulin to lower blood glucose levels, monitoring blood glucose levels to ensure they are within the target range, and administering IV fluids to correct dehydration and electrolyte imbalances. Choosing 'All of the above' as the correct answer is the most appropriate because all three interventions are essential components of DKA management. Administering insulin alone without addressing fluid status and monitoring blood glucose could lead to complications. Similarly, solely focusing on IV fluids or blood glucose monitoring without insulin administration would not effectively manage DKA.

3. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

4. When should a nurse suction a client with a tracheostomy?

• A. Every 6 hours, regardless of distress signs
• B. When the client's respiratory rate drops below 10
• C. When the client shows signs of irritability
• D. When the client begins to cough or show signs of airway blockage

Correct answer: C

Rationale: The correct answer is to suction the client when they show signs of irritability. Signs of irritability, such as restlessness or agitation, can indicate the need for suctioning in a client with a tracheostomy. This early indicator suggests that there may be an accumulation of secretions affecting the client's airway. Suctioning should be performed promptly to maintain a clear airway and prevent complications. Choices A, B, and D are incorrect because suctioning should be based on clinical signs and symptoms indicating the need for intervention, rather than a fixed schedule or specific vital sign parameters.

5. Which type of infectious diseases are required to be reported to the health department?

• A. Staphylococcus aureus infections, including MRSA
• B. Severe cases of flu-like symptoms
• C. Common colds and non-severe respiratory infections
• D. Only contagious diseases like meningitis

Correct answer: A

Rationale: The correct answer is A: Staphylococcus aureus infections, including MRSA. Severe infections like MRSA are required to be reported to the health department as they pose a significant public health risk. Choices B, C, and D are incorrect because severe flu-like symptoms, common colds, and non-severe respiratory infections, and only contagious diseases like meningitis do not fall under the category of infectious diseases that must be reported to the health department.

Similar Questions