Nursing Elites

1. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding is most concerning?

• A. Crepitus around the tracheostomy site
• B. Dry and cracked tracheostomy site
• C. Yellowing of the skin around the tracheostomy site
• D. Mucous plugging of the tracheostomy tube

Correct answer: D

Rationale: Mucous plugging of the tracheostomy tube is the most concerning finding in a client with a tracheostomy and thick secretions. This can lead to airway obstruction, which requires immediate intervention to maintain a patent airway. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but does not pose an immediate threat to the airway. A dry and cracked tracheostomy site may require interventions to promote healing but is not as urgent as mucous plugging. Yellowing of the skin around the tracheostomy site could indicate infection or impaired circulation, which should be addressed but does not pose the same immediate risk as airway obstruction.

2. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer a loop diuretic as prescribed.
• C. Administer intravenous morphine as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.

3. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which intervention should the nurse implement first?

• A. Administer intravenous calcium gluconate.
• B. Administer intravenous insulin and glucose.
• C. Administer intravenous sodium bicarbonate.
• D. Administer a loop diuretic as prescribed.

Correct answer: B

Rationale: The correct answer is to administer intravenous insulin and glucose first. This intervention helps drive potassium back into the cells, lowering serum levels effectively. Administering intravenous calcium gluconate (choice A) is used to stabilize cardiac membranes in severe hyperkalemia but does not address the underlying cause. Administering intravenous sodium bicarbonate (choice C) is used in metabolic acidosis, not hyperkalemia. Administering a loop diuretic (choice D) can help eliminate potassium but is not the first-line treatment for hyperkalemia in CKD.

4. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Watery diarrhea
• B. Nausea
• C. Headache
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.

5. A client with chronic heart failure is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?

• A. Serum potassium of 3.0 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 1.5 mg/dl
• D. Blood glucose of 200 mg/dl

Correct answer: A

Rationale: A serum potassium level of 3.0 mEq/L requires immediate intervention in a client receiving furosemide. Furosemide can cause potassium loss, leading to hypokalemia, which can be dangerous, especially in patients with heart failure. Hypokalemia can predispose the client to cardiac dysrhythmias, weakness, and other complications. Therefore, prompt intervention is necessary to prevent these adverse effects. Choice B (Serum sodium of 135 mEq/L) is within the normal range and does not require immediate intervention. Choice C (Serum creatinine of 1.5 mg/dl) may indicate kidney dysfunction but does not pose an immediate threat to the client's safety. Choice D (Blood glucose of 200 mg/dl) may suggest hyperglycemia, which is important but not as urgent as addressing hypokalemia in a client with heart failure receiving furosemide.

Similar Questions