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. During a teaching session on dietary management for heart failure, a client makes a statement. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of foods high in sodium.
• B. I should increase my intake of foods high in potassium.
• C. I should decrease my intake of fluids.
• D. I should decrease my intake of fiber.

Correct answer: C

Rationale: The correct answer is C because decreasing fluid intake is essential in managing fluid retention and symptoms of heart failure. Restricting fluids helps prevent excessive fluid buildup in the body, thus reducing the workload on the heart and alleviating symptoms like swelling and shortness of breath. Choices A, B, and D are incorrect. Increasing intake of foods high in sodium can exacerbate fluid retention and worsen heart failure symptoms. Increasing potassium-rich foods is beneficial for some heart conditions but not heart failure specifically. Decreasing fiber intake is not a standard recommendation for heart failure management.

3. A client has a new prescription for digoxin, and a nurse is providing teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I will take my pulse before taking this medication.
• B. I will take this medication with an antacid.
• C. I will double the dose if I miss one.
• D. I will avoid eating bananas.

Correct answer: A

Rationale: The correct answer is A because taking the pulse before administering digoxin is crucial as the medication can cause bradycardia. Monitoring the pulse helps in identifying any signs of bradycardia, a common side effect of digoxin. Options B, C, and D are incorrect. Taking digoxin with an antacid may interfere with its absorption. Doubling the dose if a dose is missed can lead to overdose and adverse effects. Avoiding bananas is not specifically related to digoxin therapy.

4. What action should be taken to prevent respiratory complications in a client who is postoperative?

• A. Encourage the use of an incentive spirometer.
• B. Restrict fluid intake.
• C. Place the client in a supine position.
• D. Administer a cough suppressant.

Correct answer: A

Rationale: Encouraging the use of an incentive spirometer is crucial in preventing respiratory complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, which can prevent atelectasis (lung collapse) and promote lung expansion. This, in turn, reduces the risk of respiratory complications such as pneumonia. Restricting fluid intake, placing the client in a supine position, and administering a cough suppressant are not appropriate actions for preventing respiratory complications in a postoperative client.

5. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?

• A. Massage the reddened area.
• B. Apply a donut-shaped cushion.
• C. Reposition the client every 3 hours.
• D. Use a transparent film dressing.

Correct answer: D

Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.

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