Nursing Elites

1. When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?

• A. 2 seconds
• B. 10 seconds
• C. 20 seconds
• D. 30 seconds

Correct answer: B

Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma. Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.

2. If a visitor accidentally knocks over a plastic pleural drainage system connected to a client, causing it to crack, what should the nurse do first?

• A. Observe the client's response.
• B. Notify the physician.
• C. Change the drainage system.
• D. Observe for leaks.

Correct answer: C

Rationale: When a pleural drainage system is cracked, the nurse's initial action should be to change the drainage system. This is essential to prevent potential complications like air leaks or infections. While observing the client's response and checking for leaks are important steps, they are secondary to addressing the immediate issue of the cracked system. Notifying the physician, though necessary, can be carried out once the primary concern of the damaged system is resolved.

3. A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?

• A. Administers the injection 2 inches below the acromion process
• B. Positions the client with the deltoid muscle exposed
• C. Administers the injection in the thigh
• D. Places the client in the Sims position

Correct answer: A

Rationale: When administering an intramuscular injection in the deltoid muscle, the correct technique involves administering the injection 2 inches below the acromion process, which is the bony structure on top of the shoulder blade. This location ensures safe and effective administration. Administering the injection in the thigh (vastus lateralis or rectus femoris muscle) is not appropriate for a deltoid injection as the deltoid muscle is located in the upper arm. The Sims position is not the correct position for a deltoid muscle injection. While positioning the client with the deltoid muscle exposed allows for proper access and visualization, the critical aspect for a correct deltoid injection is the accurate injection site, 2 inches below the acromion process.

4. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

• A. Rechecking the pulse oximetry reading
• B. Calling the respiratory therapist
• C. Calling the healthcare provider
• D. Oxygenating the client with 100% oxygen

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

5. A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions, and he says, "I don't want to bother the surgeon."? The nurse should ____.

• A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
• B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
• C. go get the surgeon to answer all of the client's questions
• D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed

Correct answer: D

Rationale: In this scenario, the nurse should prioritize the client's understanding and comfort. While acknowledging the client's wish not to bother the surgeon is important, it is equally crucial to ensure that the client's questions are answered appropriately and thoroughly. Choice A is correct as it respects the client's initial sentiment and offers the client the opportunity to ask questions later if needed. Choice B is incorrect as it suggests answering all questions immediately, without considering the client's feelings. Choice C is incorrect as it bypasses the nurse's role in addressing the client's concerns. Choice D, the correct answer, balances respecting the client's wish and ensuring that all questions are appropriately addressed, even if it involves the surgeon returning.

Similar Questions