Nursing Elites

1. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?

• A. Suction the tracheostomy to maintain a patent airway.
• B. Administer pain medication as prescribed.
• C. Change the tracheostomy dressing every 4 hours.
• D. Monitor the patient's oxygen saturation closely.

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.

2. A patient is being taught to use TD nitroglycerin patches to treat angina pectoris. What instructions should be included?

• A. Apply a patch every 12 hours
• B. Apply a new patch every morning
• C. Use it only when symptoms appear
• D. Rotate the application site weekly

Correct answer: B

Rationale: The correct answer is to apply a new patch every morning. Nitroglycerin patches should be applied in the morning and removed at bedtime to provide a 14-hour nitrate-free interval, preventing tolerance development. Choice A is incorrect because applying a patch every 12 hours may lead to tolerance. Choice C is incorrect because nitroglycerin patches are used prophylactically, not just when symptoms appear. Choice D is incorrect because rotating the application site weekly is not necessary; the same site can be used as long as there is no skin irritation.

3. When educating a patient with hypertension about lifestyle changes, what is the most crucial advice to provide?

• A. Advise the patient to reduce salt intake.
• B. Instruct the patient to limit alcohol consumption.
• C. Recommend the patient to exercise for 30 minutes every day.
• D. Instruct the patient to avoid high-cholesterol foods.

Correct answer: A

Rationale: The most critical lifestyle change for a patient with hypertension is to reduce salt intake. Excessive salt consumption can lead to increased blood pressure levels. While limiting alcohol consumption (Choice B) and regular exercise (Choice C) are also beneficial for managing hypertension, reducing salt intake has a more direct impact on blood pressure control. Avoiding high-cholesterol foods (Choice D) is important for heart health but may not have as significant an impact on blood pressure as reducing salt intake.

4. A client had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?

• A. Maintain foam wedge between legs
• B. Monitor for shortening of the affected leg
• C. Encourage use of elastic stockings
• D. Avoid flexing the hips more than 60 degrees

Correct answer: A

Rationale: The correct answer is to maintain a foam wedge between the legs. This intervention helps prevent hip dislocation by maintaining proper leg alignment after surgery. Monitoring for shortening of the affected leg (choice B) is not directly related to preventing dislocation. Encouraging the use of elastic stockings (choice C) is more related to preventing deep vein thrombosis rather than dislocation. Avoiding flexing the hips more than 60 degrees (choice D) is important post-surgery, but it is not the most direct intervention to prevent dislocation.

5. A nurse sees a healthcare provider administer an incorrect medication dose but does not report the error. What should the nurse do first?

• A. Ignore the situation and continue with patient care.
• B. Report the error to the nurse manager immediately.
• C. Speak to the healthcare provider directly about the error.
• D. File an anonymous report to avoid conflict.

Correct answer: B

Rationale: When a nurse witnesses a healthcare provider administering an incorrect medication dose, the first step should be to report the error to the nurse manager immediately. Reporting medication errors is crucial for patient safety as it allows prompt intervention to prevent harm. Choice A is incorrect as ignoring the situation can jeopardize patient safety. Choice C, while addressing the error directly, may not ensure proper documentation and follow-up. Choice D, filing an anonymous report, is not as effective as directly informing the nurse manager who can take appropriate action and follow-up on the incident.

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