Nursing Elites

1. What should the nurse do first when a client with a tracheostomy exhibits respiratory distress?

• A. Notify the provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct initial action when a client with a tracheostomy exhibits respiratory distress is to suction the tracheostomy. This helps to clear secretions and improve the client's ability to breathe. Notifying the provider (choice A) can cause a delay in immediate intervention. Administering a bronchodilator (choice C) may be necessary but is not the priority in this situation. Increasing the oxygen flow rate (choice D) can be helpful but should come after addressing the immediate need for suctioning to clear the airway.

2. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?

• A. Elevate the IV site and apply an ice pack
• B. Administer an anti-inflammatory medication
• C. Apply a cold compress to the IV site
• D. Discontinue the IV and notify the provider

Correct answer: D

Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.

3. What is the most important intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Monitor airway patency
• C. Provide bronchodilators
• D. Call for assistance

Correct answer: A

Rationale: Administering oxygen is crucial in managing a patient experiencing respiratory distress. Oxygen therapy helps to improve oxygen levels in the blood, supporting vital organ functions. While monitoring airway patency is important, administering oxygen takes precedence in ensuring the patient receives an adequate oxygen supply. Providing bronchodilators may be beneficial in certain respiratory conditions, but the immediate priority in distress is to address oxygenation. Calling for assistance is essential, but the immediate intervention to support the patient's respiratory function is administering oxygen.

4. A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?

• A. Place a bed exit alarm
• B. Use restraints to prevent the client from getting out of bed
• C. Ask the client's family to stay at the bedside
• D. Encourage frequent ambulation with assistance

Correct answer: A

Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.

5. A client expresses doubt about the benefits of surgery. Which response by the nurse is most appropriate?

• A. Ask the client to explain why they believe the surgery won't help.
• B. Comment on the client's doubt regarding the procedure's benefits.
• C. Assure the client that everything will be fine.
• D. Acknowledge the client's uncertainty about the surgery.

Correct answer: D

Rationale: Option D is the most appropriate response as it acknowledges the client's expressed uncertainty about the surgery. By acknowledging the client's feelings, the nurse validates their concerns and opens the door for further discussion. This approach can help build trust and rapport with the client. Option A focuses more on seeking justification for the client's belief rather than addressing the underlying emotion. Option B, while acknowledging doubt, does not directly address the client's feelings. Option C, although well-intentioned, dismisses the client's concerns without exploring them further.

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