Nursing Elites

1. Which of the following is an early indication that a tracheostomy client requires suctioning?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased respiratory rate

Correct answer: B

Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.

2. A nurse is teaching a client who is taking warfarin about food and medication interactions. Which of the following foods should the nurse instruct the client to avoid?

• A. Tomatoes
• B. Apples
• C. Broccoli
• D. Green leafy vegetables

Correct answer: D

Rationale: Correct Answer: Green leafy vegetables - Green leafy vegetables are high in vitamin K, which can interfere with the effectiveness of warfarin. Tomatoes, apples, and broccoli are not contraindicated with warfarin therapy. While they are healthy choices, they do not have a significant impact on warfarin's effectiveness.

3. A nurse is reinforcing teaching about using a cane with a client who has left-leg weakness. What instruction should the nurse give?

• A. Use the cane on the weaker side
• B. Advance the cane and the strong leg together
• C. Maintain two points of support on the floor at all times
• D. Advance the cane 30 to 45 cm with each step

Correct answer: C

Rationale: The correct instruction for a client with left-leg weakness using a cane is to maintain two points of support on the floor at all times. This technique provides stability and support while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice B is incorrect as advancing the cane and the strong leg together may not provide adequate support and balance. Choice D is incorrect as the distance to advance the cane with each step can vary depending on the individual's needs and abilities.

4. A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

• A. Drink plenty of fluids after meals
• B. Increase sugar intake
• C. Eat smaller, more frequent meals
• D. Avoid foods high in sugar content

Correct answer: D

Rationale: The correct instruction the nurse should include in teaching a client with dumping syndrome is to 'Avoid foods high in sugar content.' Dumping syndrome occurs when high-sugar foods move too quickly into the small intestine, leading to symptoms like abdominal cramps, diarrhea, and bloating. By avoiding foods high in sugar content, the client can reduce these symptoms. Choices A, B, and C are incorrect. Drinking plenty of fluids after meals may exacerbate symptoms by speeding up the movement of food through the digestive system. Increasing sugar intake would worsen dumping syndrome symptoms. While eating smaller, more frequent meals is a good strategy, the key emphasis should be on avoiding high-sugar foods.

5. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?

• A. The child is placed in a private room
• B. The staff removes a toy from the child's bed and takes it to the nurse's station
• C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack
• D. The staff uses standard precautions

Correct answer: A

Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.

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