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. A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?

• A. Holding the device securely when changing ties
• B. Suctioning the client first if secretions are present
• C. Tying a square knot at the back of the neck
• D. Using half-strength peroxide for cleansing

Correct answer: C

Rationale: When providing tracheostomy care, it is important to ensure the client's safety and prevent pressure ulcers. When securing ties that require knotting, the knot should be placed at the side of the client's neck, not at the back. Tying a square knot at the back of the neck could lead to discomfort, pressure ulcers, or accidental tightening. Holding the device securely, suctioning the client as needed, and using appropriate cleansing solutions are all essential components of tracheostomy care.

3. When reviewing the provider's orders, a nurse recognizes that clarification is needed for which of the following medications in a client experiencing an exacerbation of asthma?

• A. Propranolol
• B. Theophylline
• C. Montelukast
• D. Prednisone

Correct answer: A

Rationale: The correct answer is Propranolol. Propranolol is a beta-blocker that can potentially exacerbate asthma symptoms due to its mechanism of action. It can cause bronchoconstriction, which is harmful for a client experiencing an asthma exacerbation. Theophylline, Montelukast, and Prednisone are commonly used in the treatment of asthma exacerbations and would not typically require clarification in this context.

4. A client interested in smoking cessation is being taught by a nurse. Which statements should the nurse include in the teaching? (Select one that does not apply)

• A. Find an activity that you enjoy and will keep your hands busy.
• B. Keep snacks like potato chips on hand to nibble on.
• C. Drink at least eight glasses of water each day.
• D. Make a list of reasons for quitting smoking.

Correct answer: C

Rationale: When teaching a client interested in smoking cessation, the nurse should advise finding an activity that keeps the hands busy, keeping healthy snacks on hand, making a list of reasons for quitting smoking, and not being upset if a relapse occurs. Drinking eight glasses of water each day is a healthy habit but is not directly related to smoking cessation strategies, making it the option that does not apply in this context.

5. During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

• A. Breathing ranging from very deep to very shallow with periods of apnea
• B. Shallow to normal breaths alternating with periods of apnea
• C. Rapid respirations that are unusually deep and regular
• D. An inability to breathe without dyspnea unless sitting upright

Correct answer: A

Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.

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