Nursing Elites

1. A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

• A. Rest in a side-lying position after the tube is removed.
• B. Use the incentive spirometer every 4 hours after the tube is removed.
• C. Avoid speaking for extended periods.
• D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.

Correct answer: C

Rationale: It is essential to advise the client to avoid speaking for extended periods after the removal of the endotracheal tube to prevent strain on the vocal cords and allow the airway to recover. Speaking for prolonged periods can lead to irritation and potentially affect the healing process. The other options are also important post-extubation instructions, such as using the incentive spirometer to maintain lung function, positioning in a side-lying position for comfort, and frequent monitoring of vital signs to ensure the client's stability.

2. When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?

• A. A client who is scheduled for an abdominal x-ray and is awaiting transport
• B. A client who has a prescription for discharge
• C. A client who received oral pain medication 30 minutes ago
• D. A client who told an assistive personnel he is short of breath

Correct answer: D

Rationale: When a client expresses being short of breath, it may indicate a serious condition requiring immediate attention to ensure adequate oxygenation. This client should be seen first to assess the severity of the situation and initiate appropriate interventions. The other options, such as awaiting transport for an x-ray, having a prescription for discharge, or receiving oral pain medication 30 minutes ago, do not present immediate life-threatening concerns compared to a client experiencing shortness of breath.

3. When performing tracheostomy care, which intervention should the nurse implement?

• A. Use aseptic technique.
• B. Clean the inner cannula with mild soap and water.
• C. Secure new tracheostomy ties before removing old ones.
• D. Apply suction when inserting the catheter.

Correct answer: C

Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.

4. How can a nurse manager best improve hand-off communication among the staff? (SATA)

• A. Attending hand-off rounds to coach and mentor.
• B. Conducting audits of staff using a new template.
• C. Creating a template of topics to include in the report.
• D. Utilizing the SHARE model as a tool for standardizing hand-off reports and other critical communication.

Correct answer: D

Rationale: The SHARE model is a valuable tool for standardizing hand-off reports and other critical communication. By utilizing this model, the nurse manager can ensure consistency and clarity in hand-off communication among the staff. While attending hand-off rounds to coach and mentor, conducting audits using a new template, and creating a template of topics to include in the report can all be beneficial actions, the most effective approach to achieve the goal of improving hand-off communication is by implementing a standardized tool like the SHARE model.

5. A student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select one that does not apply)

• A. Age
• B. Hypertension
• C. Obesity
• D. Smoking

Correct answer: A

Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease, as they can be changed or controlled through interventions. Age, on the other hand, is a nonmodifiable risk factor, meaning it cannot be altered. Understanding the difference between modifiable and nonmodifiable risk factors is essential in preventive healthcare strategies.

Similar Questions