Nursing Elites

1. A client is being taught about the use of an incentive spirometer. Which statement by the client indicates effective teaching?

• A. I will use the spirometer every hour while awake.
• B. I will blow into the spirometer as hard as I can.
• C. I should feel dizzy when using the spirometer.
• D. I will only use the spirometer if I feel short of breath.

Correct answer: A

Rationale: The correct answer is A because using the spirometer every hour while awake is an effective way to prevent respiratory complications. This frequency helps in maintaining lung function and preventing atelectasis. Choice B is incorrect because blowing too hard into the spirometer can lead to hyperventilation and dizziness, making choice C also incorrect. Choice D is wrong as waiting to use the spirometer only when feeling short of breath may not provide optimal lung expansion and can lead to respiratory issues.

2. A nurse in a health clinic is caring for a 20-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client?

• A. Testicular examination
• B. Blood glucose
• C. Fecal occult blood
• D. Prostate-specific antigen

Correct answer: A

Rationale: A testicular examination is appropriate for a 20-year-old male to screen for testicular cancer, which is more common in younger age groups. Testicular cancer is most frequently diagnosed in individuals between the ages of 15 and 40. Blood glucose screening is typically recommended for older individuals or those at risk for diabetes. Fecal occult blood testing is used for colorectal cancer screening, usually starting at age 50. Prostate-specific antigen testing is commonly considered for prostate cancer screening in older males, typically around age 50. Therefore, the most appropriate screening for the 20-year-old client is the testicular examination.

3. When teaching a client and their family how to care for the client’s tracheostomy at home, which of the following should the nurse include?

• A. Use tracheostomy covers when outdoors
• B. Maintain a sterile technique when performing tracheostomy care
• C. Do not remove the outer cannula for routine cleaning
• D. Clean around the stoma with normal saline solution

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice D) is not advisable as it can be irritating to the skin and may impair the healing process.

4. When caring for a client with a tracheostomy, which of the following actions should the nurse take?

• A. Clean the skin around the stoma with normal saline.
• B. Secure the tracheostomy ties with two fingers' width underneath.
• C. Soak the outer cannula in warm tap water.
• D. Use a cotton tip applicator to clean the inside of the inner cannula.

Correct answer: A

Rationale: When caring for a client with a tracheostomy, the nurse should clean the skin around the stoma with normal saline to prevent infection and ensure cleanliness. This action helps in maintaining skin integrity and preventing skin breakdown. Securing the tracheostomy ties with two fingers' width underneath is essential to allow for proper fit, prevent skin irritation, and ensure the ties are not too tight. Soaking the outer cannula in warm tap water is not recommended as it can lead to contamination and is not a standard practice. Using a cotton tip applicator to clean the inside of the inner cannula is discouraged as it can leave fibers behind, increasing the risk of aspiration and respiratory complications.

5. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.

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