Nursing Elites

1. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

2. How should a healthcare professional assess a patient with a tracheostomy?

• A. Monitor for infection and ensure airway patency
• B. Suction airway secretions and provide humidified oxygen
• C. Clean the stoma and change tracheostomy ties
• D. Educate the patient on tracheostomy care

Correct answer: A

Rationale: Corrected Question: To assess a patient with a tracheostomy, the healthcare professional should primarily focus on monitoring for infection and ensuring the airway remains patent. Choice A is the correct answer as these actions are crucial for tracheostomy management. Suctioning airway secretions and providing humidified oxygen (Choice B) are interventions that may be necessary based on the assessment findings but are not the initial assessment steps. Similarly, cleaning the stoma and changing tracheostomy ties (Choice C) are important aspects of tracheostomy care but do not specifically address the initial assessment. Educating the patient on tracheostomy care (Choice D) is important, but it is not the primary assessment action needed when assessing a patient with a tracheostomy.

3. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

• A. Encourage deep breathing exercises
• B. Maintain the client in a supine position
• C. Apply a sequential compression device
• D. Massage the client's legs

Correct answer: C

Rationale: The correct answer is C: Apply a sequential compression device. Applying a sequential compression device promotes venous return by assisting with blood circulation in the lower extremities, reducing the risk of blood clots. Encouraging deep breathing exercises can help with lung expansion but does not directly promote venous return. Maintaining the client in a supine position may not be ideal for promoting venous return if the client is unable to move. Massaging the client's legs may be contraindicated postoperatively due to the risk of dislodging a clot or causing trauma to the surgical site.

4. A client with peripheral arterial disease (PAD) is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Apply lotion between the toes
• B. Wear shoes that fit properly
• C. Walk barefoot at home
• D. Apply ice to the feet daily

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes that fit properly.' In peripheral arterial disease (PAD), it is crucial to wear shoes that fit well to prevent foot injuries. Choice A is incorrect because applying lotion between the toes can increase the risk of infection. Choice C is incorrect since walking barefoot at home can lead to injuries, especially in individuals with PAD. Choice D is incorrect as applying ice to the feet daily can further reduce blood flow to the extremities, worsening the condition in PAD.

5. What are the key components of a focused respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Observation, Percussion, Auscultation, Palpation
• C. Auscultation, Palpation, Observation, Percussion
• D. Palpation, Inspection, Auscultation, Percussion

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for any abnormalities, palpating to assess tenderness and chest expansion, percussion to evaluate underlying structures, and auscultation to listen to lung sounds. Choice B is incorrect because observation is generally part of inspection, not a separate component. Choice C is incorrect as auscultation should come before percussion in a respiratory assessment. Choice D is incorrect because inspection should precede palpation in a structured assessment.

Similar Questions