Nursing Elites

1. A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

• A. Request an occupational therapy consult to determine the need for assistive devices
• B. Assign assistive personnel to perform self-care tasks for the client
• C. Instruct the client to focus on gradually resuming self-care tasks
• D. Ask the client if a family member is available to assist with his care

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence following an acute myocardial infarction. This approach allows the client to regain confidence and control over their self-care activities without feeling overwhelmed. Requesting an occupational therapy consult (Choice A) may be beneficial but is not the immediate solution to promote independence. Assigning assistive personnel (Choice B) to perform tasks for the client does not encourage independence. Asking if a family member is available for assistance (Choice D) does not directly promote the client's independence.

2. A nurse is teaching a client who is to undergo total knee arthroplasty about postoperative care. Which of the following instructions should the nurse include?

• A. Apply heat to the affected knee
• B. Avoid placing pillows under the knee
• C. Avoid moving the knee for 2-3 days
• D. Apply ice to the affected knee for 24-48 hours

Correct answer: D

Rationale: The correct answer is to apply ice to the affected knee for 24-48 hours. Applying ice helps to reduce inflammation and pain after knee surgery, promoting healing. Choice A is incorrect because heat is not recommended postoperatively, as it can increase swelling. Choice B is incorrect because pillows should be placed under the knee to keep it elevated. Choice C is incorrect because early mobilization is essential for preventing complications such as blood clots.

3. Which of the following is an early indicator that a client with a tracheostomy may require suctioning?

• A. Decreased respiratory rate
• B. Irritability
• C. Bradycardia
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early indicator that suctioning is necessary for a client with a tracheostomy. Irritability can signal discomfort or difficulty breathing, which may be due to the need for suctioning to clear the airway. Decreased respiratory rate, bradycardia, and decreased oxygen saturation are not typically early indicators that suctioning is needed in a client with a tracheostomy. These symptoms may occur later if the airway is not cleared promptly.

4. A client with type 2 diabetes mellitus is being taught about insulin administration by a nurse. Which of the following instructions should the nurse include?

• A. Inject insulin into the muscle
• B. Rotate injection sites with each dose
• C. Store insulin at room temperature
• D. Massage the injection site after administration

Correct answer: B

Rationale: The correct instruction that the nurse should include is to rotate injection sites with each dose. This practice is essential to prevent tissue damage and ensure proper insulin absorption. Option A is incorrect because insulin should not be injected into the muscle, but rather into the subcutaneous tissue. Option C is incorrect as insulin should be stored in the refrigerator to maintain its effectiveness. Option D is incorrect as massaging the injection site after administration can lead to faster absorption and potentially hypoglycemia.

5. 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.

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