Nursing Elites

1. A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include?

• A. Use tracheostomy covers when going outdoors.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Do not remove the outer cannula for routine cleaning.
• D. Clean around the stoma with normal saline.

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when going outdoors. This instruction is important as it helps protect the airway from dust and other particles, reducing the risk of infection or irritation. Choice B is incorrect because maintaining sterile technique is crucial during tracheostomy care to prevent infections, but it is not the most pertinent instruction in this scenario. Choice C is incorrect as removing the outer cannula is not a routine cleaning procedure and should only be done by healthcare professionals when necessary. Choice D is incorrect because cleaning around the stoma with normal saline is not recommended as it can cause irritation to the skin and stoma site.

2. A client who has a new prescription for warfarin (Coumadin) is receiving discharge teaching from a nurse. Which of the following statements indicates that the client understands the teaching?

• A. I will take my warfarin at the same time every day.
• B. I should use a soft-bristled toothbrush while taking this medication.
• C. I should take my warfarin at bedtime.
• D. I should avoid eating foods high in vitamin K while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Taking warfarin at the same time every day is essential to maintain a consistent blood level of the medication. This statement indicates that the client understands the teaching about the importance of consistency in medication timing. Choice B, regarding using a soft-bristled toothbrush, is not directly related to warfarin therapy and does not assess the client's understanding of warfarin administration. Choice C suggesting taking warfarin at bedtime is incorrect; it is generally recommended to take warfarin at the same time each day to avoid variations in drug levels. Choice D about avoiding foods high in vitamin K is relevant as vitamin K can interfere with warfarin's anticoagulant effects. However, it is not the best indicator of understanding the teaching on medication timing, which is crucial for warfarin efficacy.

3. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

4. A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?

• A. “I am afraid to walk if it hurts too much.”
• B. “I don’t understand why I need this surgery.”
• C. “I don’t want my family helping me after the surgery.”
• D. “I am afraid the scar will make me look disfigured.”

Correct answer: B

Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.

5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Mitral stenosis
• C. Aortic regurgitation
• D. Tricuspid stenosis

Correct answer: B

Rationale: The correct answer is B: Mitral stenosis. A high-pitched scratching sound heard during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border indicates mitral stenosis, not a pericardial friction rub. Pericardial friction rub is a to-and-fro, grating, or scratching sound due to inflamed pericardial surfaces rubbing together, typically heard in early diastole and late systole. Aortic regurgitation and tricuspid stenosis would present with different auscultatory findings compared to the described scenario, making them incorrect choices in this context.

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