Nursing Elites

1. Which of the following is an early indicator that a client with a tracheostomy may require suctioning?

• A. Decreased respiratory rate
• B. Irritability
• C. Bradycardia
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early indicator that suctioning is necessary for a client with a tracheostomy. Irritability can signal discomfort or difficulty breathing, which may be due to the need for suctioning to clear the airway. Decreased respiratory rate, bradycardia, and decreased oxygen saturation are not typically early indicators that suctioning is needed in a client with a tracheostomy. These symptoms may occur later if the airway is not cleared promptly.

2. A client with heart failure is on a fluid restriction. What should the nurse include in the discharge teaching?

• A. Encourage the client to drink more water to stay hydrated
• B. Monitor the client's weight daily
• C. Avoid drinking water after 6 PM
• D. Monitor fluid intake only during meals

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily.' In clients with heart failure on fluid restriction, monitoring daily weight is crucial to track fluid balance. This allows healthcare providers to assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink more water contradicts the fluid restriction; avoiding drinking water after 6 PM is not specific to managing fluid restriction; and monitoring fluid intake only during meals does not provide a comprehensive assessment of fluid balance throughout the day.

3. What are the complications of untreated deep vein thrombosis (DVT)?

• A. Pulmonary embolism and stroke
• B. Kidney failure and hypertension
• C. Liver failure and electrolyte imbalance
• D. Fluid overload and bradycardia

Correct answer: A

Rationale: Corrected Rationale: Untreated DVT can lead to complications such as pulmonary embolism and stroke. Pulmonary embolism occurs when a blood clot from the leg travels to the lungs, potentially blocking blood flow and causing respiratory distress. Stroke can occur if a blood clot dislodges from the leg veins, travels to the brain, and obstructs a blood vessel, leading to brain tissue damage. Both of these complications are life-threatening if not managed promptly. The other choices (B, C, D) do not represent common complications of untreated DVT and are therefore incorrect.

4. A client has hyperthermia. Which of the following actions should the nurse take?

• A. Submerge the client's feet in ice water.
• B. Cover the client with a thermal blanket.
• C. Administer oral acetaminophen.
• D. Initiate seizure precautions.

Correct answer: C

Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.

5. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

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