Nursing Elites

1. The nurse is providing care for a client with a new tracheostomy. Which of these assessments is a priority?

• A. Checking the client's oxygen saturation level
• B. Monitoring the client's pain level
• C. Checking the tracheostomy site for signs of infection
• D. Monitoring the client's level of consciousness

Correct answer: C

Rationale: When caring for a client with a new tracheostomy, the priority assessment is checking the tracheostomy site for signs of infection. This is essential to detect early signs of complications such as infection, which can lead to serious issues. Monitoring oxygen saturation is important but not as critical as ensuring the tracheostomy site is free from infection. Pain assessment and level of consciousness are also important but secondary to assessing for signs of infection in this scenario.

2. Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?

• A. Assessing the client's level of consciousness
• B. Monitoring the client's oxygen saturation
• C. Checking the client's gag reflex before eating or drinking
• D. Monitoring the client's intake and output

Correct answer: C

Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.

3. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?

• A. A heart rate of 72 beats per minute
• B. A blood pressure of 110/70 mm Hg
• C. Pupils equal and reactive to light
• D. Client reports headache

Correct answer: C

Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.

4. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

• A. drowsiness
• B. complaint of nausea
• C. pulse rate of 92
• D. restlessness

Correct answer: D

Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.

5. A nurse is reinforcing teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate?

• A. Drink carbonated beverages.
• B. Decrease fiber intake.
• C. Use bronchodilators after meals.
• D. Increase protein intake.

Correct answer: D

Rationale: The correct answer is to instruct the client to increase protein intake. This is appropriate because increasing protein intake can help maintain muscle mass and strength in clients with COPD. Option A, 'Drink carbonated beverages,' is incorrect as carbonated beverages can exacerbate COPD symptoms. Option B, 'Decrease fiber intake,' is also incorrect as fiber is important for digestion and should not be decreased unless specifically advised by a healthcare provider. Option C, 'Use bronchodilators after meals,' is incorrect because bronchodilators are typically used before meals to help open the airways for better breathing, not after meals.

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