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. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?

• A. Administer glucagon IM
• B. Give the client 4 oz of fruit juice
• C. Provide the client with peanut butter
• D. Give the client 1 L of water

Correct answer: B

Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.

3. What is the priority intervention when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Administer sedative medication to control agitation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.

4. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

• A. A history of gastroesophageal reflux disease.
• B. Receiving a formula with high osmolarity.
• C. Sitting in a high-Fowler's position during the feeding.
• D. A residual of 65 mL 1 hour postprandial.

Correct answer: A

Rationale: The correct answer is A: A history of gastroesophageal reflux disease. Clients with gastroesophageal reflux disease have a higher risk of aspiration during tube feeding due to the potential for reflux of stomach contents into the lungs. This increases the risk of aspiration pneumonia. Choices B, C, and D are incorrect. High osmolarity formulas may cause diarrhea but do not directly increase the risk of aspiration. Sitting in a high-Fowler's position actually reduces the risk of aspiration by promoting proper digestion and reducing the chance of regurgitation. A residual of 65 mL 1 hour postprandial is within an acceptable range and does not directly indicate a risk for aspiration.

5. A nurse is reinforcing teaching about cane use for a client with left-leg weakness. What should the nurse instruct the client to do?

• A. Use the cane on the weak side
• B. Maintain two points of support on the ground at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: B

Rationale: The correct answer is B: Maintain two points of support on the ground at all times. When using a cane for left-leg weakness, the client should hold the cane in the right hand and advance the cane and the weak leg simultaneously. This technique provides the necessary support and stability. Option A is incorrect because the cane should be used on the side opposite the weakness to provide support. Option C is incorrect as advancing the cane too far with each step may cause the client to lose balance. Option D is incorrect because advancing the cane and the strong leg simultaneously does not provide the needed support for the weakened leg.

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