Nursing Elites

1. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

• A. Suction deeper to remove secretions.
• B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
• C. Remove the suction as quickly as possible.
• D. Insert and remove the suction multiple times to clear secretions.

Correct answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.

2. A seriously ill female client tells the nurse, 'I am so tired and in so much pain! Please help me to die.' Which is the best response for the nurse to provide?

• A. Administer the prescribed maximum dose of pain medication.
• B. Talk with the client about her feelings related to her own death.
• C. Collaborate with the healthcare provider about initiating antidepressant therapy.
• D. Refer the client to the ethics committee of her local healthcare facility.

Correct answer: B

Rationale: The nurse should prioritize addressing the client's emotional needs by engaging in a conversation to understand the underlying feelings behind her statement. By exploring the client's thoughts about death, the nurse can provide appropriate support and interventions tailored to the client's concerns. Rushing to administer pain medication may not address the emotional distress expressed by the client. Initiating antidepressant therapy is not suitable without assessing the client's feelings further. Referring the client to the ethics committee is premature and does not address the immediate emotional needs of the client. Therefore, empathetic communication and assessment of the client's feelings regarding her situation are crucial for providing holistic care.

3. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

• A. Only refer to the client by gender.
• B. Identify the client only by age.
• C. Avoid using the client's name.
• D. Discuss the client another time.

Correct answer: D

Rationale: The best nursing action is to discuss the client another time. When discussing a client's confidential information, it is essential to ensure privacy and confidentiality. Given the presence of other clients in the immediate vicinity, it is inappropriate to discuss personal details about a client's condition openly. Waiting for a more private setting is crucial to uphold the client's right to privacy and confidentiality. Choices A, B, and C are not appropriate because referring to the client only by gender, age, or avoiding the client's name does not address the issue of discussing confidential information in a public setting, which compromises the client's privacy and confidentiality.

4. When turning an immobile bedridden client without assistance, which action best ensures client safety?

• A. Securely grasp the client's arm and leg.
• B. Put bed rails up on the side of bed opposite from the nurse.
• C. Correctly position and use a turn sheet.
• D. Lower the head of the client's bed slowly.

Correct answer: B

Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.

5. The healthcare professional is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the healthcare professional include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: To maintain patency and ensure proper medication delivery, water should be instilled into the feeding tube between administering the two medications. This helps prevent clogging of the tube and ensures that both medications are delivered effectively without interference from remnants of the previous medication. Diluting the medications with sterile water before administration (choice A) is unnecessary and may alter the medication concentration. Mixing the medications in one syringe (choice B) could lead to interactions or chemical reactions between the medications. Withdrawing fluid from the tube before instilling each medication (choice D) is not required and may increase the risk of tube displacement or misplacement.

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