Nursing Elites

1. A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?

• A. Holding the device securely when changing ties
• B. Suctioning the client first if secretions are present
• C. Tying a square knot at the back of the neck
• D. Using half-strength peroxide for cleansing

Correct answer: C

Rationale: When providing tracheostomy care, it is important to ensure the client's safety and prevent pressure ulcers. When securing ties that require knotting, the knot should be placed at the side of the client's neck, not at the back. Tying a square knot at the back of the neck could lead to discomfort, pressure ulcers, or accidental tightening. Holding the device securely, suctioning the client as needed, and using appropriate cleansing solutions are all essential components of tracheostomy care.

2. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?

• A. Bring a list of all medications and their purposes.
• B. Keep the doctor's phone number close by.
• C. Ensure all providers wash their hands before entering the room.
• D. Document the name of each caregiver who enters the room.

Correct answer: A

Rationale: The most important action a client can take to protect against errors is to bring a list of all medications and their purposes. This helps ensure that the healthcare team has accurate information about the client's medications, reducing the risk of medication errors, which are the most common type of healthcare mistake. Knowing the medications and their purposes can also aid in preventing drug interactions and adverse effects during the surgical procedure.

3. A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?

• A. Widened QRS complexes
• B. Hyperactive deep tendon reflexes
• C. Bounding peripheral pulses
• D. Warm, flushed skin

Correct answer: A

Rationale: Respiratory acidosis is a condition characterized by increased carbon dioxide levels in the blood, resulting in acidosis. One of the potential consequences of respiratory acidosis is the development of electrolyte imbalances, particularly hyperkalemia. Hyperkalemia can lead to cardiac conduction abnormalities, manifested as widened QRS complexes on an electrocardiogram (ECG). Therefore, in a client with respiratory acidosis, the healthcare professional should expect to find widened QRS complexes as a result of the associated hyperkalemia.

4. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

• A. The client who has been NPO since midnight for endoscopy
• B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
• C. The client who has end-stage renal failure and is scheduled for dialysis today
• D. The client who has gastroenteritis and is febrile

Correct answer: D

Rationale: Gastroenteritis can lead to fluid loss through vomiting and diarrhea, especially when accompanied by fever. Fever can increase insensible water loss through sweating as well. Both vomiting and diarrhea can significantly contribute to fluid volume deficit, making the client with gastroenteritis and fever at higher risk compared to the other clients described in the options.

5. A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?

• A. I will reduce my sodium intake to help control my blood pressure.
• B. I need to start walking at least 30 minutes most days of the week.
• C. I can continue drinking alcohol as long as it is not in excess.
• D. I will check my blood pressure regularly at home.

Correct answer: C

Rationale: In hypertension management, it is crucial for clients to limit or avoid alcohol consumption, not just refrain from excess. Alcohol can raise blood pressure and interfere with the effectiveness of antihypertensive medications, making it a key lifestyle modification for individuals with hypertension.

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