Nursing Elites

1. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

• A. Providing humidified oxygen
• B. Ensuring the tracheostomy ties are secure
• C. Suctioning the tracheostomy tube as needed
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

2. A client post-lobectomy is placed on mechanical ventilation. The nurse notices the client is fighting the ventilator. What should the nurse do first?

• A. Increase the sedation as prescribed.
• B. Manually ventilate the client using an ambu bag.
• C. Check the ventilator settings and alarms.
• D. Suction the client’s airway.

Correct answer: C

Rationale: The correct first action for the nurse to take when a client is fighting the ventilator is to check the ventilator settings and alarms. This step is crucial to ensure that the ventilator is functioning correctly and providing the necessary support to the client. Increasing sedation (Choice A) should only be considered after confirming that the ventilator settings are appropriate. While manually ventilating the client (Choice B) may be required in some cases, it is not the initial action to take. Suctioning the client's airway (Choice D) is not the priority in this situation, where the primary concern is addressing the client's struggle with the ventilator.

3. Which type of cell is responsible for producing antibodies in the immune system?

• A. B lymphocytes
• B. T lymphocytes
• C. Macrophages
• D. Neutrophils

Correct answer: A

Rationale: The correct answer is A: B lymphocytes. B lymphocytes (B cells) are a crucial part of the adaptive immune system. They produce antibodies, which are proteins that specifically target and neutralize pathogens such as bacteria and viruses. T lymphocytes (choice B) are involved in cell-mediated immunity rather than antibody production. Macrophages (choice C) are phagocytic cells that engulf and digest pathogens but do not produce antibodies. Neutrophils (choice D) are a type of white blood cell that primarily function in the innate immune response by phagocytosing pathogens.

4. During a clinic visit for a sore throat, a client's basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which intervention should the PN recommend to the client based on this finding?

• A. Increase intake of dried peaches and apricots
• B. Reduce intake of red meats
• C. Encourage use of a soft toothbrush
• D. Force fluid intake to 1500 mL daily

Correct answer: A

Rationale: The correct answer is to recommend increasing the intake of dried peaches and apricots. A serum potassium level of 3.0 mEq/L is considered low. Increasing the intake of potassium-rich foods can help raise the serum potassium level, preventing complications such as muscle weakness and cardiac arrhythmias. Choice B, reducing intake of red meats, is incorrect because red meats are not specifically related to potassium levels. Choice C, encouraging the use of a soft toothbrush, is unrelated to addressing low potassium levels. Choice D, forcing fluid intake to 1500 mL daily, is not the appropriate intervention for low serum potassium; instead, increasing potassium-rich foods is more beneficial.

5. The home health PN suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the PN to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: The most important action for the PN to take in this situation is to report the findings to the supervisor for referral to adult protective services. Suspected elder abuse must be reported promptly to ensure the safety and protection of the client. Documenting the lacerations in the client's record is important but not as critical as reporting the suspected abuse. Asking the daughter who is the potential abuser may not yield accurate information and could compromise the safety of the client. Applying dressings to the wounds is a lower priority compared to addressing the suspected elder abuse.

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