Nursing Elites

1. A nurse is assigned to care for four clients. Which client should the nurse assess first?

• A. A client scheduled for a colonoscopy
• B. A client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask
• C. A client preparing for discharge after surgery
• D. A client requiring a tube feeding through a gastrostomy tube

Correct answer: B

Rationale: The correct answer is a client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask. Airway management is always the priority in nursing care. Assessing this client first ensures that their airway is clear and oxygenation is adequate. Clients with compromised airways need immediate attention to prevent respiratory distress or failure. The other clients do not have immediate airway concerns and represent lower priorities in this scenario. Therefore, the nurse should prioritize assessing the client with the tracheostomy and oxygen therapy to maintain airway patency and adequate oxygenation.

2. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

• A. Rechecking the pulse oximetry reading
• B. Calling the respiratory therapist
• C. Calling the healthcare provider
• D. Oxygenating the client with 100% oxygen

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

3. Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:

• A. tolerance.
• B. constipation.
• C. sedation.
• D. addiction.

Correct answer: D

Rationale: When caring for clients with cancer who are taking opioids, nurses need to assess for tolerance, constipation, and sedation as these are common side effects of opioid use. Addiction, however, is not a primary concern when treating pain in terminally ill clients. Terminally ill patients are usually not at risk of developing addiction to opioids due to their short life expectancy and the focus on pain management rather than the potential for addiction. Therefore, the correct answer is 'addiction.' Choices A, B, and C are essential considerations when managing clients on opioids for pain control.

4. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:

• A. monitoring intravenous infusion
• B. assisting a client to the bathroom
• C. offering fluid intake every 1-2 hours
• D. monitoring/recording the amount of fluid taken

Correct answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

5. Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?

• A. Impaired Physical Mobility
• B. Dysreflexia
• C. Hypothermia
• D. Impaired Dentition

Correct answer: A

Rationale: The correct answer is 'Impaired Physical Mobility.' As Parkinson's disease progresses, clients may experience a shuffling gait and rigidity, leading to impaired physical mobility. This nursing diagnosis is relevant to address the functional limitations that may arise. 'Dysreflexia' is not typically associated with Parkinson's disease but rather with spinal cord injuries. 'Hypothermia' is a condition of abnormally low body temperature and is not a common complication of Parkinson's disease. 'Impaired Dentition' refers to dental issues and is not directly related to the progression of Parkinson's disease.

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