Nursing Elites

1. A nursing student is suctioning a client through a tracheostomy tube while a nurse observes. Which action by the student would prompt the nurse to intervene and demonstrate the correct procedure? Select all that apply.

• A. Setting the suction pressure to 60 mm Hg
• B. Applying suction throughout the procedure
• C. Assessing breath sounds before suctioning
• D. Placing the client in a supine position before the procedure

Correct answer: A

Rationale: The correct suction pressure for an adult client with a tracheostomy tube is typically between 80 to 120 mm Hg. Suction should be applied intermittently during catheter withdrawal to avoid damaging the airway. Assessing breath sounds before suctioning is important to ensure the procedure is necessary. Placing the client in a supine position before suctioning can compromise their airway; instead, the head of the bed should be elevated to facilitate proper drainage and reduce the risk of aspiration. Therefore, setting the suction pressure to 60 mm Hg is incorrect and would prompt the nurse to intervene and correct the procedure.

2. After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?

• A. Irregular pulse rhythm
• B. Bile-colored emesis
• C. ST elevation in three leads
• D. Complaint of radiating jaw pain

Correct answer: C

Rationale: ST elevation in three leads is a critical finding that suggests myocardial infarction, requiring immediate attention. This finding indicates ischemia or injury to the heart muscle. Choices A, B, and D are not as critical in this scenario. Irregular pulse rhythm may be concerning but does not indicate an immediate life-threatening condition like myocardial infarction. Bile-colored emesis and complaint of radiating jaw pain are relevant but not as indicative of a myocardial infarction as ST elevation in three leads.

3. A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL. After the nurse calls the physician to report the finding and monitors the client closely for:

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: In the scenario described, a client with a blood glucose level of 620 mg/dL and type 1 diabetes mellitus is at risk of developing metabolic acidosis. In type 1 diabetes, the lack of sufficient circulating insulin leads to an increase in blood glucose levels. As the body cells utilize all available glucose, the breakdown of fats for energy results in the production of ketones, leading to metabolic acidosis. Metabolic alkalosis, respiratory acidosis, and respiratory alkalosis are not typically associated with uncontrolled type 1 diabetes. Metabolic alkalosis is more commonly linked to conditions such as vomiting or excessive diuretic use, while respiratory acidosis and respiratory alkalosis are related to respiratory system imbalances in carbon dioxide levels.

4. The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?

• A. Potassium 6.0 mEq/L.
• B. Daily urine output of 400 ml.
• C. Peripheral neuropathy.
• D. Uremic fetor.

Correct answer: A

Rationale: The correct answer is A. Potassium level of 6.0 mEq/L indicates hyperkalemia, which is a critical electrolyte imbalance in clients with chronic kidney disease. Hyperkalemia can lead to life-threatening arrhythmias, making it the priority finding to address. Choice B, a daily urine output of 400 ml, may indicate decreased kidney function but does not pose an immediate life-threatening risk compared to hyperkalemia. Peripheral neuropathy (Choice C) and uremic fetor (Choice D) are common manifestations of CKD but are not as urgent as addressing a potentially fatal electrolyte imbalance like hyperkalemia.

5. A client who is receiving chemotherapy asks the nurse, 'Why is so much of my hair falling out each day?' Which response by the nurse best explains the reason for alopecia?

• A. 'Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.'
• B. 'Alopecia is a common side effect you will experience during long-term steroid therapy.'
• C. 'Your hair will grow back completely after your course of chemotherapy is completed.'
• D. 'The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss.'

Correct answer: A

Rationale: The correct answer is A: 'Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.' Chemotherapy targets rapidly dividing cells, which include not only cancer cells but also healthy cells like those in hair follicles. This leads to alopecia (hair loss) as a common side effect. Choice B is incorrect as alopecia is primarily associated with chemotherapy and not long-term steroid therapy. Choice C is incorrect because while hair may grow back after chemotherapy, it may not always be to the same extent or thickness. Choice D is incorrect as chemotherapy-induced hair loss is often temporary and reversible, not permanent alterations in hair follicles.

Similar Questions