Nursing Elites

1. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

• A. Increase wall suction while removing the suction catheter
• B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
• C. Suction the client’s oropharynx after tracheal suctioning
• D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

2. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

3. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

• A. The client has asymmetrical chest wall expansion
• B. The client complains of pain at the insertion site
• C. The client's chest x-ray indicates decreased pleural effusion
• D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26

Correct answer: A

Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.

4. A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client’s plan of care?

• A. High risk for infection related to subclavian catheter
• B. High risk of injury related to ambulation
• C. Knowledge deficit related to a high-protein diet
• D. Hygiene self-care deficit related to uremic frost

Correct answer: D

Rationale: The correct answer is D. Uremic frost is a condition in which urea and other waste products are excreted through the skin, leaving a powdery residue. This indicates poor hygiene and self-care, common issues in patients with CKD and renal osteodystrophy. Proper hygiene measures are essential to prevent complications. Choices A, B, and C are less likely to be included in the plan of care for a CKD patient with renal osteodystrophy. Choice A is more related to a vascular access issue, choice B is more related to mobility concerns, and choice C is more related to dietary education.

5. A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.)

• A. Increased heart rate
• B. Visual disturbances
• C. Presence of uremic frost
• D. Decreased mentation

Correct answer: A

Rationale: The correct signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) include increased heart rate, visual disturbances, and decreased mentation. These symptoms are often associated with HHNS due to the high blood glucose levels. Uremic frost, a sign of advanced kidney disease, is not typically associated with HHNS. Therefore, choices B and D are incorrect. However, choice C, 'Presence of uremic frost,' is incorrect as it is not typically associated with HHNS.

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