Nursing Elites

1. A client has a tracheostomy and requires suctioning. Which of the following actions should be taken?

• A. Hyperoxygenate the client before suctioning
• B. Insert the catheter while exhalation
• C. Apply suction after inserting the catheter
• D. Limit suctioning to no more than 15 seconds

Correct answer: A

Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.

2. During a teaching session on dietary management for heart failure, a client makes a statement. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of foods high in sodium.
• B. I should increase my intake of foods high in potassium.
• C. I should decrease my intake of fluids.
• D. I should decrease my intake of fiber.

Correct answer: C

Rationale: The correct answer is C because decreasing fluid intake is essential in managing fluid retention and symptoms of heart failure. Restricting fluids helps prevent excessive fluid buildup in the body, thus reducing the workload on the heart and alleviating symptoms like swelling and shortness of breath. Choices A, B, and D are incorrect. Increasing intake of foods high in sodium can exacerbate fluid retention and worsen heart failure symptoms. Increasing potassium-rich foods is beneficial for some heart conditions but not heart failure specifically. Decreasing fiber intake is not a standard recommendation for heart failure management.

3. A client has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

• A. Apply a fecal collection system
• B. Apply a barrier cream
• C. Cleanse and dry the area
• D. Check the client's perineum

Correct answer: D

Rationale: When a client with major fecal incontinence reports irritation in the perianal area, the nurse's initial action should be to assess the client's perineum to gather more information. By checking the perineum, the nurse can identify the extent and nature of the irritation, allowing for appropriate interventions to be initiated. This assessment is crucial in developing a comprehensive care plan and addressing the client's immediate needs effectively. Applying the nursing process priority-setting framework helps in planning care and prioritizing nursing actions, making assessment the initial step in this scenario. Applying a fecal collection system (choice A) would be premature without assessing the perineal area first. Similarly, applying a barrier cream (choice B) or cleansing and drying the area (choice C) should follow the assessment to ensure appropriate interventions are chosen based on the assessment findings.

4. A healthcare professional is planning care for a client who has a new prescription for a high-protein diet. Which of the following foods should the healthcare professional recommend?

• A. Nuts
• B. Bananas
• C. Potatoes
• D. Apples

Correct answer: A

Rationale: Nuts are an excellent source of protein and are suitable for a high-protein diet. They provide essential nutrients and can help the client meet their increased protein requirements. Bananas, potatoes, and apples are not high-protein foods and are not the best choice when aiming to increase protein intake.

5. A client has a new prescription for a low-fat diet. Which of the following foods should be recommended?

• A. Bacon
• B. Whole milk
• C. Chicken breast
• D. Cheese

Correct answer: C

Rationale: When following a low-fat diet, it is essential to choose foods that are low in fat. Chicken breast is a lean protein source that is low in fat, making it a suitable option for a low-fat diet. Bacon, whole milk, and cheese are higher in fat content and should be avoided or limited in a low-fat diet. Bacon is high in saturated fat, whole milk contains significant amounts of fat, including saturated fat, and cheese is also high in fat. Therefore, these options are not ideal for a low-fat diet.

Similar Questions