Nursing Elites

1. While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?

• A. Notify the operating room of a potential emergency case.
• B. No action is required at this time; this pulsation can be a normal finding in some clients.
• C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
• D. Stay with the client and ask someone else to contact the provider immediately.

Correct answer: D

Rationale: The pulsation of the tracheostomy tube with the heartbeat may indicate a tracheoinnominate artery fistula, which can lead to life-threatening hemorrhage if the artery is breached. In this scenario, as there is no active bleeding yet, the nurse should remain with the client and have another person notify the provider immediately. If the client starts to hemorrhage, the nurse should remove the tracheostomy tube and apply pressure at the bleeding site, preparing the client for urgent surgical intervention.

2. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?

• A. "We can teach you some relaxation techniques to minimize your pain."
• B. "Keep wire cutters with you at all times."
• C. "Use a water pick device to keep your teeth clean."
• D. "Consume a high-protein, liquid diet."

Correct answer: B

Rationale:

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 healthcare professional is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the healthcare professional administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 4 mL
• B. 6 mL
• C. 10 mL
• D. 5.5 mL

Correct answer: A

Rationale: To calculate the mL of albuterol syrup needed per dose, first, determine how many milligrams are in the prescribed dose: 1.6 mg. Next, set up a proportion to find the equivalent mL for 1.6 mg using the given concentration of 2 mg/5mL. The calculation is: (1.6 mg x 5 mL) / 2 mg = 4 mL. Therefore, the correct answer is 4 mL to administer per dose.

5. During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?

• A. Dirty carpets requiring vacuuming
• B. Expired food found in the refrigerator
• C. Outdated medications stored in the kitchen
• D. Presence of multiple cats in the home

Correct answer: B

Rationale: The presence of expired food in the refrigerator is concerning as it raises safety issues for the client and indicates potential financial constraints preventing them from buying fresh food. The nurse should consider referring the client to services like Meals on Wheels or other home-based food programs to address this issue and ensure the client's nutritional needs are met.

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