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 client undergoing surgery is being taught about the use of a patient-controlled analgesia (PCA) pump by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will ask my spouse to push the button when I am sleeping
• B. I will use the PCA pump to keep me comfortable during the night
• C. I will ask the nurse to increase the dosage if I still feel pain
• D. I will press the button for medication as soon as I feel pain

Correct answer: D

Rationale: The correct answer is D because clients should press the button on the PCA pump when they feel pain to receive controlled doses of medication. Option A is incorrect as the client should be the one to self-administer the medication through the PCA pump. Option B is incorrect as the primary purpose of the PCA pump is to manage pain, not to keep the client comfortable. Option C is incorrect because the client should not adjust the dosage themselves; instead, they should communicate any pain concerns to the healthcare provider.

3. A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

• A. Monitor the client's fluid and electrolyte balance
• B. Consult a dietitian to improve the client's nutritional status
• C. Administer a protein supplement
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

4. What are the side effects of chemotherapy, and how should they be managed?

• A. Nausea, vomiting; manage with antiemetics
• B. Hair loss and anemia; manage with blood transfusions
• C. Diarrhea and fatigue; manage with hydration
• D. Weight gain and high blood pressure; manage with diuretics

Correct answer: A

Rationale: The correct side effects of chemotherapy mentioned in this question are nausea and vomiting. These side effects are commonly managed with antiemetics to improve the quality of life for patients undergoing chemotherapy. Choice B (Hair loss and anemia) is incorrect as hair loss and anemia are potential side effects of chemotherapy but are not addressed in this question. Choice C (Diarrhea and fatigue) is also incorrect as it does not match the side effects provided. Choice D (Weight gain and high blood pressure) is inaccurate as these are not typical side effects of chemotherapy.

5. A nurse is caring for a client who is taking digoxin. Which of the following findings should the nurse identify as a sign of digoxin toxicity?

• A. Bradycardia
• B. Tachycardia
• C. Hypotension
• D. Hyperkalemia

Correct answer: A

Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a cardiac glycoside, can lead to toxicity manifesting as bradycardia due to its effect on the heart's electrical conduction system. Tachycardia (choice B) is not typically associated with digoxin toxicity. Hypotension (choice C) and hyperkalemia (choice D) are not direct signs of digoxin toxicity. Therefore, the correct answer is bradycardia.

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