Nursing Elites

1. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

• A. Why don’t we now have the client turn back to the left side.
• B. That was done correctly. Did you have any problems with the insertion?
• C. Let’s check to see if the suppository is in far enough.
• D. Did you feel any stool in the intestinal tract?

Correct answer: B

Rationale: The appropriate comment by the nurse is to affirm the correct technique while offering support and checking for any issues during the insertion.

2. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which instruction should the LPN/LVN reinforce to the client to help manage their condition?

• A. Increase fluid intake to thin secretions.
• B. Practice pursed-lip breathing to improve oxygenation.
• C. Avoid physical activity to prevent dyspnea.
• D. Use a peak flow meter to monitor lung function.

Correct answer: B

Rationale: Practicing pursed-lip breathing is an essential technique to help manage COPD as it can improve oxygenation by promoting better gas exchange. This technique helps to keep the airways open longer during exhalation, preventing air trapping and improving breathing efficiency. Increasing fluid intake can help thin secretions, which is beneficial, but it is not the primary instruction for managing COPD. Avoiding physical activity is not recommended as it can lead to deconditioning and worsen dyspnea in COPD patients. Using a peak flow meter is more commonly associated with monitoring asthma rather than COPD, so it is not the most relevant instruction for managing COPD.

3. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

• A. Obtaining cotton balls for the tracheostomy care
• B. Using a sterile water bottle
• C. Checking the suction equipment
• D. Wearing a sterile gown

Correct answer: A

Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.

4. The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?

• A. Droplet precautions
• B. Airborne precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: B

Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.

5. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Decrease in heart rate
• B. Fluid volume deficit causes tachycardia
• C. Decrease in blood pressure
• D. Increase in respiratory rate

Correct answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

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