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. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

• A. Place the client in the wheelchair for four hours each day
• B. Pad the bony prominences
• C. Reposition every two hours
• D. Massage reddened bony prominence

Correct answer: C

Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.

3. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares the elimination of which element?

• A. Sodium
• B. Potassium
• C. Phosphate
• D. Albumin

Correct answer: B

Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps retain potassium while eliminating sodium. This is beneficial for patients with cirrhosis and ascites as they are at risk of low potassium levels. Choice A, Sodium, is incorrect as Spironolactone does not spare the elimination of sodium but rather helps eliminate it. Choice C, Phosphate, is incorrect as Spironolactone does not directly affect phosphate levels. Choice D, Albumin, is incorrect as Spironolactone does not spare the elimination of albumin.

4. A client who is pregnant and has hyperemesis gravidarum is being taught about nutrition at home by a nurse. Which of the following statements indicate that the client understands the teachings?

• A. I will drink water with my meals.
• B. I will eat every 6 hours throughout the day.
• C. I will eat crackers before I get out of bed in the morning.
• D. I will limit my protein intake.

Correct answer: C

Rationale: The correct answer is C. Eating crackers before getting out of bed can help manage nausea associated with hyperemesis gravidarum. Choice A is incorrect because drinking water with meals may exacerbate nausea. Choice B is incorrect as eating every 6 hours may not be frequent enough to combat nausea and vomiting. Choice D is incorrect because protein intake should not be limited during pregnancy, especially in cases of hyperemesis gravidarum.

5. The client is receiving discharge teaching for heart failure. Which statement made by the client indicates a need for further teaching?

• A. I will weigh myself daily and report any significant weight gain to my healthcare provider.
• B. I will limit my sodium intake to help manage my heart failure.
• C. I will take my medications as prescribed by my healthcare provider.
• D. I will stop taking my medications if I feel better.

Correct answer: D

Rationale: Choice D is the correct answer because stopping medications when feeling better can be harmful in heart failure. It is essential to complete the full course of medication as prescribed by the healthcare provider to effectively manage heart failure. Choices A, B, and C demonstrate good understanding and compliance with heart failure management strategies, such as monitoring weight, restricting sodium intake, and adhering to prescribed medications, respectively.

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