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 is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?

• A. Apply heat packs to the area
• B. Use perfumed soap to cleanse the area
• C. Keep the area moist with lotion
• D. Avoid sun exposure to the treated area

Correct answer: D

Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.

3. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

• A. Educate the client about their current medical diagnosis.
• B. Refer the client to a meal delivery program.
• C. Identify environmental hazards in the home.
• D. Arrange transportation for the client to follow-up appointments.

Correct answer: C

Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.

4. A nurse is teaching a client with hypertension about using a blood pressure monitor. Which of the following instructions should the nurse include?

• A. Take your blood pressure after eating
• B. Sit quietly for 5 minutes before taking your blood pressure
• C. Use a blood pressure cuff that is too small
• D. Take your blood pressure while standing

Correct answer: B

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before taking their blood pressure. This is important because sitting quietly helps stabilize the heart rate, leading to a more accurate reading. Choice A is incorrect because taking blood pressure after eating can affect the readings. Choice C is wrong because using a blood pressure cuff that is too small can provide inaccurate readings. Choice D is also incorrect as blood pressure should be taken in a seated position for accurate results.

5. A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?

• A. Frequency
• B. Dosage
• C. Timing of doses
• D. Route

Correct answer: B

Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.

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