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 in a provider's office is reviewing the laboratory results of a group of clients. Which result is reportable?

• A. Herpes simplex
• B. Human papillomavirus
• C. Candidiasis
• D. Chlamydia

Correct answer: D

Rationale: Chlamydia is a reportable sexually transmitted infection. Reporting cases of Chlamydia to the health department is crucial for disease surveillance, contact tracing, and implementing public health interventions. Herpes simplex, human papillomavirus, and candidiasis are not typically reportable infections, as they do not pose the same public health risks as Chlamydia.

3. A client at risk for osteoporosis is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid weight-bearing exercises.
• B. I should increase my intake of vitamin D.
• C. I should reduce my intake of dairy products.
• D. I will increase my intake of foods high in calcium.

Correct answer: B

Rationale: The correct answer is B: 'I should increase my intake of vitamin D.' Adequate vitamin D intake is crucial for calcium absorption, which is essential for bone health and preventing osteoporosis. Avoiding weight-bearing exercises (choice A) would be detrimental as weight-bearing activities help improve bone density. Reducing dairy intake (choice C) is not recommended as dairy products are a good source of calcium. While increasing calcium intake (choice D) is important, ensuring sufficient vitamin D levels for proper absorption is equally crucial for bone health.

4. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Chest tube drainage of 60 mL/hr
• B. Oxygen saturation of 95%
• C. Chest tube drainage of 120 mL/hr
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

5. A client is receiving heparin therapy. Which of the following laboratory results indicates the client is receiving an effective dose of heparin?

• A. INR 1.5
• B. aPTT 60 seconds
• C. Platelets 150,000/mm³
• D. Potassium 4.0 mEq/L

Correct answer: B

Rationale: An aPTT of 60 seconds indicates the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for a clot to form, and a therapeutic range for heparin therapy is usually 1.5 to 2 times the control value, which is around 60-80 seconds. An INR of 1.5 is not related to heparin therapy, as it is commonly used to monitor warfarin therapy. Platelet count and potassium levels are not direct indicators of the effectiveness of heparin therapy.

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