Nursing Elites

1. A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included:

• A. Cotton balls
• B. Sterile gloves
• C. A suction catheter
• D. Tracheostomy tubes

Correct answer: A

Rationale: The correct answer is A: Cotton balls. Cotton balls are not suitable for tracheostomy care due to the risk of lint and contamination. When performing tracheostomy care, sterile supplies such as sterile gloves, a suction catheter, and tracheostomy tubes are essential. Sterile gloves are needed to maintain asepsis, a suction catheter is necessary for airway clearance, and tracheostomy tubes are crucial for maintaining a patent airway. Cotton balls should be avoided to prevent introducing lint or fibers into the tracheostomy site, which can lead to infection or airway obstruction.

2. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?

• A. pH below 7.3
• B. Potassium of 5.0
• C. HCT of 60
• D. PaO2 of 79%

Correct answer: C

Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.

3. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Notify the nursing manager.
• B. Document the client's condition and communication with the surgeon.
• C. Administer additional fluids as per standard procedure.
• D. Call the surgeon back immediately to ensure timely intervention.

Correct answer: B

Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.

4. What instruction should the nurse provide for a UAP caring for a client with MRSA who has a prescription for contact precautions?

• A. Allow visitors with precautions in place
• B. Wear sterile gloves when handling the client's body fluid
• C. Have the client wear a mask whenever someone enters the room
• D. Don a gown and gloves when entering the room

Correct answer: D

Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the room. Wearing a gown and gloves is necessary to prevent the transmission of MRSA. Choice A is incorrect because visitors may be allowed with proper precautions in place. Choice B is incorrect as it assumes the client has body fluid precautions, which is not specified. Choice C is incorrect as it does not address the UAP's protective measures but rather focuses on the client wearing a mask.

5. While auscultating the anterior chest of a newly admitted patient, what would the nurse expect to hear?

• A. Normal breathing sounds
• B. Wheezing
• C. Crackles
• D. Stridor

Correct answer: A

Rationale: When auscultating the chest, normal breathing sounds are expected in a healthy individual. Wheezing is a high-pitched whistling sound that indicates narrowed airways and is often heard in conditions like asthma. Crackles are fine, crackling sounds heard on inspiration or expiration and are associated with conditions like pneumonia or heart failure. Stridor is a high-pitched, harsh sound heard during inspiration due to upper airway obstruction. Therefore, choices B, C, and D indicate abnormal respiratory findings, while choice A signifies normal breathing sounds.

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