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. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?

• A. Hip pallor
• B. Leg abduction
• C. Muscle spasms
• D. Leg lengthening

Correct answer: C

Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.

3. A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (SATA)

• A. Change the client's position
• B. Identify the client's pain level
• C. Remind the client to use incisional splinting
• D. Offer the client a back rub

Correct answer: A

Rationale: The correct actions the nurse should take when caring for a client postoperative following a cholecystectomy and reporting pain include changing the client's position. This can help relieve postoperative pain by reducing pressure on the surgical site. Identifying the client's pain level is important but not specific to alleviating postoperative pain. While reminding the client to use incisional splinting can be beneficial, it may not directly address the immediate pain concern. Offering the client a back rub is not typically indicated for postoperative pain relief after a cholecystectomy.

4. A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?

• A. An abnormal stance
• B. Injury to the nerves
• C. A fall and further injury
• D. Skin breakdown

Correct answer: B

Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.

5. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

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