Nursing Elites

1. What is the priority nursing intervention for a patient with a new tracheostomy?

• A. Suction the tracheostomy as needed to maintain a patent airway.
• B. Monitor the patient's oxygen saturation.
• C. Provide humidified air to prevent drying of the airway.
• D. Administer pain medication as prescribed.

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy as needed to maintain a patent airway. After a tracheostomy procedure, the immediate concern is airway patency to prevent respiratory compromise. Suctioning helps clear secretions and maintains a clear airway, reducing the risk of respiratory distress. Monitoring the patient's oxygen saturation (choice B) is important but not the priority compared to ensuring a clear airway. Providing humidified air (choice C) and administering pain medication (choice D) are also essential aspects of care for a patient with a tracheostomy, but they are not the priority when immediate airway management is required.

2. Which action should the nurse take to minimize the risk of medication errors?

• A. Prepare medications ahead of time to ensure they are ready.
• B. Ensure two nurses double-check medications before administration.
• C. Administer medications at the same time each day.
• D. Rely on memory to administer the correct medications.

Correct answer: B

Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.

3. The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, 'I always get a rash when I eat shellfish.' Which of the following is the priority nursing action?

• A. Attach a wristband indicating the client's allergy
• B. Ask the client if any other foods cause such a reaction
• C. Notify the dietary department of the client's allergy
• D. Notify the provider of the client's allergy

Correct answer: D

Rationale: Notifying the provider of the client's shellfish allergy is crucial to prevent a potential reaction from the contrast dye. While attaching a wristband indicating the allergy may be necessary, the priority is to inform the provider. Asking the client about other foods causing a similar reaction or notifying the dietary department, although important, are not the priority in this situation.

4. A nurse is using the ecologic model for population health to develop interventions to address HIV in a community. Which of the following interventions should the nurse include to address financial factors affecting community health?

• A. Have adolescents lead peer discussions in schools about safe sexual practices
• B. Distribute condoms through remote community clinics
• C. Create commercial advertisements describing the long-term effects of HIV
• D. Include information about perinatal HIV transmission at prenatal education classes

Correct answer: B

Rationale: The correct answer is B. Distributing condoms addresses financial barriers by providing access to essential protective measures in remote areas. Choice A focuses on education rather than direct intervention related to financial factors. Choice C involves advertising and not a direct intervention to address financial factors. Choice D pertains to education about HIV transmission rather than directly addressing financial barriers affecting community health.

5. A client has a prescription for vancomycin 1g IV intermittent infusion over 30 minutes every 12 hours. What action should the nurse take?

• A. Start the infusion immediately
• B. Slow down the infusion rate
• C. Contact the provider for prescription clarification
• D. Check blood pressure during the infusion

Correct answer: C

Rationale: The correct action for the nurse to take is to contact the provider for prescription clarification. Administering vancomycin over less than 60 minutes can lead to infusion reactions like hypotension and flushing. Starting the infusion immediately (choice A) is incorrect as it goes against the prescribed rate. Slowing down the infusion rate (choice B) without provider approval can result in underdosing the medication. Checking blood pressure during the infusion (choice D) is important but not the most immediate action needed in this situation.

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