Nursing Elites

1. The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?

• A. Encourage the client to take deep breaths.
• B. Provide humidified oxygen via tracheostomy collar.
• C. Suction the tracheostomy tube as needed.
• D. Change the tracheostomy dressing daily.

Correct answer: C

Rationale: Suctioning the tracheostomy tube as needed is the most appropriate action in this scenario. When a client with a tracheostomy is unable to clear secretions by coughing, suctioning helps remove the excess secretions from the airway, ensuring proper breathing. Encouraging deep breaths (Choice A) may not effectively address the immediate need to clear secretions. Providing humidified oxygen (Choice B) can help with oxygenation but does not directly address the issue of clearing secretions. Changing the tracheostomy dressing daily (Choice D) is important for maintaining cleanliness but is not the priority when the client is unable to clear secretions.

2. A healthcare professional is preparing for change of shift. Which document or tool should the healthcare professional use to communicate?

• A. SBAR
• B. SOAP
• C. DAR
• D. PIE

Correct answer: A

Rationale: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating critical information during shift changes or handoffs. It helps to ensure important details about a patient's condition and care are effectively communicated. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a note-taking format used in healthcare to document patient encounters, but it is not specifically designed for shift handoffs. Choice C, DAR (Data, Action, Response), and choice D, PIE (Problem, Intervention, Evaluation), are not commonly used communication tools during shift changes in healthcare settings. Therefore, the correct choice is SBAR for effective communication during shift handoffs.

3. A nurse is caring for a client who has herpes zoster. The client asks about complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

• A. Acupuncture
• B. Massage therapy
• C. Aromatherapy
• D. Herbal supplements

Correct answer: A

Rationale: The correct answer is A, Acupuncture. Acupuncture is contraindicated for clients with herpes zoster due to the risk of infection at the needle sites. In individuals with herpes zoster, the skin's integrity is compromised, increasing susceptibility to infections. Therefore, acupuncture, which involves inserting needles into the skin, can introduce pathogens and lead to local infections. Massage therapy (B), aromatherapy (C), and herbal supplements (D) do not involve skin penetration like acupuncture and are generally considered safe complementary therapies for pain control in clients with herpes zoster.

4. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

• A. Cleanse the entry port prior to withdrawing urine.
• B. Use a sterile syringe to collect urine from the collection bag.
• C. Obtain the specimen from the drainage tubing.
• D. Replace the catheter before obtaining the specimen.

Correct answer: A

Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.

5. A client is contemplating retirement and expresses uncertainty about wanting to retire. Which of the following responses should the nurse make?

• A. Let’s talk about how the change in your job status will affect you.
• B. Have you considered the financial implications of retirement?
• C. What are your thoughts on retirement and how it may impact your life?
• D. Would you like to discuss potential activities you could engage in during retirement?

Correct answer: A

Rationale: Choosing option A, 'Let’s talk about how the change in your job status will affect you,' is the most appropriate response in this scenario. By discussing how retirement might affect the client, the nurse can address the client's concerns and emotions about the impending change. Option B, 'Have you considered the financial implications of retirement?' is not the best response as it focuses solely on financial aspects and does not address the client's emotional readiness for retirement. Option C, 'What are your thoughts on retirement and how it may impact your life?' is more open-ended and may not address the immediate concerns of the client expressing uncertainty. Option D, 'Would you like to discuss potential activities you could engage in during retirement?' assumes the client is certain about retiring and focuses on activities rather than addressing the client's feelings of uncertainty.

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