Nursing Elites

1. During tracheostomy care, what action should a healthcare professional take?

• A. Use clean technique to remove the inner cannula.
• B. Remove the outer cannula for cleaning.
• C. Soak the inner cannula in normal saline.
• D. Change tracheostomy ties if they are wet.

Correct answer: D

Rationale: Changing tracheostomy ties if they are wet is essential to prevent infection and maintain skin integrity. Wet ties can harbor bacteria, increasing the risk of skin breakdown and other complications. Regularly changing wet ties promotes cleanliness, reduces the likelihood of complications, and ensures optimal care for the client with a tracheostomy.

2. When caring for a client with a prescription for wound irrigation, which action should the nurse take?

• A. Use a 10-mL syringe with an 18-gauge needle.
• B. Cleanse the wound from the center outward.
• C. Apply a wet-to-dry dressing.
• D. Pack the wound tightly with gauze.

Correct answer: B

Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.

3. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

4. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

• A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
• B. Wear clean gloves before inserting the tubing
• C. Position the client on their left side
• D. Hold the solution bag 91 cm (36 inches) above the client's rectum

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

5. A healthcare professional is preparing to administer an IM injection to a client. Which of the following techniques should the healthcare professional use to reduce discomfort?

• A. Use a 25-gauge needle.
• B. Administer the injection slowly.
• C. Massage the site after the injection.
• D. Apply ice to the injection site before administration.

Correct answer: B

Rationale: Administering the injection slowly is the recommended technique to reduce discomfort associated with IM injections. This approach allows the medication to disperse more gradually into the muscle, minimizing the sensation of pressure or pain during administration. Administering the injection slowly can also help prevent tissue damage and reduce the likelihood of injection site reactions.

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