Nursing Elites

1. What is the first step in managing a patient with a suspected pneumothorax?

• A. Insert a chest tube
• B. Monitor respiratory status
• C. Administer oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to insert a chest tube. In managing a patient with a suspected pneumothorax, the priority is to relieve the pressure from the pneumothorax by inserting a chest tube. Monitoring respiratory status (choice B) is important but comes after ensuring proper management of the pneumothorax. Administering oxygen (choice C) can help support oxygenation but does not address the underlying issue of pressure in the thoracic cavity. Calling for assistance (choice D) can be done concurrently with managing the pneumothorax, but the immediate intervention to address the pneumothorax itself is chest tube insertion.

2. A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?

• A. Provide teaching to the parents
• B. Report suspected abuse to the appropriate agency
• C. Document the injuries and monitor the child
• D. Counsel the parents privately

Correct answer: B

Rationale: In cases where a child's injuries are inconsistent with the parent's stated cause, it raises concerns about possible abuse. The correct action for the nurse in this situation is to report suspected abuse to the appropriate agency. This is a legal and ethical obligation for healthcare professionals when they suspect child abuse. Providing teaching to the parents (Choice A) may not address the immediate safety concerns of the child. Documenting the injuries and monitoring the child (Choice C) is important but reporting suspected abuse takes precedence to ensure the child's safety. Counseling the parents privately (Choice D) may not be effective if abuse is suspected, as the primary focus should be on protecting the child.

3. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?

• A. Ask the client to discuss their feelings
• B. Explain the importance of the medications
• C. Document the refusal and withhold the medication
• D. Inform the client of the possible consequences of refusal

Correct answer: D

Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.

4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?

• A. Monitor the client's temperature every 4 hours
• B. Monitor blood glucose levels every 6 hours
• C. Administer insulin as prescribed
• D. Monitor daily fluid intake

Correct answer: B

Rationale: Corrected Rationale: Monitoring blood glucose levels is crucial in clients receiving TPN because the solution has a high glucose content. This monitoring helps prevent hyperglycemia and allows for timely adjustments in the TPN formulation if needed. Monitoring the client's temperature (Choice A) is not directly related to TPN administration. Administering insulin (Choice C) should be based on blood glucose levels and the healthcare provider's orders; it is not a standard intervention for all clients on TPN. Monitoring daily fluid intake (Choice D) is important for overall fluid balance but is not as critical as monitoring blood glucose levels specifically for clients on TPN.

5. How should a healthcare professional assess a patient with a tracheostomy?

• A. Monitor for infection and ensure airway patency
• B. Suction airway secretions and provide humidified oxygen
• C. Clean the stoma and change tracheostomy ties
• D. Educate the patient on tracheostomy care

Correct answer: A

Rationale: Corrected Question: To assess a patient with a tracheostomy, the healthcare professional should primarily focus on monitoring for infection and ensuring the airway remains patent. Choice A is the correct answer as these actions are crucial for tracheostomy management. Suctioning airway secretions and providing humidified oxygen (Choice B) are interventions that may be necessary based on the assessment findings but are not the initial assessment steps. Similarly, cleaning the stoma and changing tracheostomy ties (Choice C) are important aspects of tracheostomy care but do not specifically address the initial assessment. Educating the patient on tracheostomy care (Choice D) is important, but it is not the primary assessment action needed when assessing a patient with a tracheostomy.

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