Nursing Elites

1. When performing tracheostomy care, which intervention should the nurse implement?

• A. Use aseptic technique.
• B. Clean the inner cannula with mild soap and water.
• C. Secure new tracheostomy ties before removing old ones.
• D. Apply suction when inserting the catheter.

Correct answer: C

Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.

2. During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?

• A. Nausea
• B. Dysphagia
• C. Agitation
• D. Hypotension

Correct answer: C

Rationale: During an asthma attack, hypoxemia can lead to inadequate oxygen supply to the brain, causing symptoms like restlessness, confusion, and agitation. These manifestations result from the body's response to low oxygen levels, aiming to increase oxygenation. Nausea, dysphagia, and hypotension are not typical manifestations of hypoxemia during an asthma attack.

3. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

• A. Increased respiratory rate from 18 to 44/min
• B. Increased oral temperature from 36.6� C (97.8� F) to 37� C (98.6� F)
• C. Increased blood pressure from 112/68 to 120/72 mm Hg
• D. Increased heart rate from 68 to 72/min

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

4. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?

• A. Production of pink sputum
• B. Tracheal deviation
• C. Drainage greater than 70 mL/hr
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.

5. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

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