Nursing Elites

1. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

• A. Use sterile technique when performing tracheostomy care.
• B. Replace the tracheostomy ties every 24 hours.
• C. Use a sterile brush to clean the inner cannula.
• D. Change the tracheostomy dressing once a week.

Correct answer: C

Rationale: The correct answer is to use a sterile brush to clean the inner cannula. This action is crucial to prevent infection during tracheostomy care. Choice A is incorrect as clean technique is not adequate for tracheostomy care, sterile technique is required. Choice B is incorrect as tracheostomy ties should be replaced when soiled, not routinely every 24 hours. Choice D is incorrect as tracheostomy dressings should be changed more frequently to maintain cleanliness and prevent infection.

2. A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?

• A. Place the client in droplet isolation.
• B. Place the client in airborne isolation.
• C. Wear a surgical mask when providing care to the client.
• D. Keep the client's door closed at all times.

Correct answer: B

Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.

3. A client has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. Avoid taking antacids at the same time as this medication.
• C. Take this medication if your heart rate is above 100/min.
• D. Notify your provider if you experience nausea or visual changes.

Correct answer: D

Rationale: The correct instruction the nurse should include for a client prescribed digoxin is to notify the provider if they experience nausea or visual changes, as these symptoms can indicate digoxin toxicity. Option A is incorrect because digoxin should be taken on an empty stomach for better absorption. Option B is incorrect as antacids can interfere with the absorption of digoxin. Option C is incorrect as taking digoxin based on heart rate alone is not appropriate.

4. A nurse is planning care for a client who has dementia and is frequently agitated. Which of the following interventions should the nurse include in the plan of care?

• A. Offer the client several choices when scheduling activities.
• B. Confront the client when inappropriate behavior occurs.
• C. Use a calm, reassuring approach when speaking to the client.
• D. Encourage the client to engage in stimulating activities.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.

5. What is the first action to take for a patient experiencing a seizure?

• A. Administer anticonvulsant medication
• B. Protect the patient's head
• C. Insert an oral airway
• D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

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