Nursing Elites

1. A client is postoperative following a rhinoplasty, and a nurse is contributing to the plan of care. Which of the following interventions should the nurse recommend?

• A. Administer humidified oxygen
• B. Restrict fluids
• C. Instruct the client to avoid the Valsalva maneuver
• D. Apply heat packs to the nose

Correct answer: C

Rationale: Instructing the client to avoid the Valsalva maneuver is crucial after rhinoplasty to reduce strain and the risk of bleeding. Administering humidified oxygen may not be directly related to postoperative care for rhinoplasty. Restricting fluids is not typically necessary unless specifically indicated by the healthcare provider. Applying heat packs to the nose is contraindicated after rhinoplasty as it can increase the risk of bleeding and should be avoided.

2. What is an early sign indicating the need for suctioning a client's tracheostomy?

• A. Irritability
• B. Hypotension
• C. Flushing
• D. Bradycardia

Correct answer: A

Rationale: Irritability is a crucial early sign that a client with a tracheostomy may require suctioning. Irritability could indicate a lack of oxygenation due to the airway blockage, prompting the need for suctioning to clear the airway. Hypotension, flushing, and bradycardia are not typically direct indicators for suctioning a tracheostomy. Hypotension may suggest hemodynamic instability, flushing could be related to autonomic responses, and bradycardia might indicate a cardiac issue rather than the need for suctioning.

3. A healthcare provider is checking a newborn's vital signs. Which of the following methods of temperature measurement should the healthcare provider use?

• A. Rectal
• B. Axillary
• C. Oral
• D. Tympanic

Correct answer: B

Rationale: The axillary method is the most appropriate for newborns because it is non-invasive and safe. Rectal temperature measurement can be uncomfortable and poses a risk of injury, especially in newborns. Oral temperature measurement is not recommended for newborns due to their inability to cooperate and potential inaccuracies. Tympanic temperature measurement may not be as accurate in newborns compared to older children or adults.

4. A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?

• A. Use abdominal breathing during physical activity
• B. Inhale quickly and deeply through the nose
• C. Use pursed-lip breathing during physical activity
• D. Breathe quickly and deeply during exercise

Correct answer: C

Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.

5. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

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