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. When assessing a client's skin turgor, a nurse should:

• A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
• B. Check skin elasticity on the back of the hand
• C. Press on the skin over the abdomen
• D. Measure skin turgor on the lower leg

Correct answer: A

Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.

3. The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?

• A. Weight gain
• B. Heat intolerance
• C. Increased appetite
• D. Frequent diarrhea

Correct answer: A

Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.

4. What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?

• A. Place the pillow under the patient's head and shoulders.
• B. Attempt to do it alone if the bed is in a flat position.
• C. Place the side rails in the up position.
• D. Use a friction-reducing device.

Correct answer: D

Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.

5. When interviewing the parents of a child with asthma, what information about the child's environment should be gathered most importantly?

• A. Household pets
• B. New furniture
• C. Lead-based paint
• D. Plants such as cactus

Correct answer: A

Rationale: When assessing a child with asthma, it is crucial to gather information about potential triggers in their environment. Household pets, such as cats or dogs, are common triggers for asthma attacks due to pet dander and saliva. This information is essential to identify if exposure to pets at home could be exacerbating the child's asthma symptoms. Choices B, C, and D are less relevant in the context of asthma triggers. New furniture, lead-based paint, and plants like cactus are not typically primary triggers for asthma attacks compared to common allergens like pet dander.

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