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 nurse is caring for a client who has a prescription for metoprolol. For which of the following findings should the nurse withhold the medication?

• A. Heart rate 56/min.
• B. Oxygen saturation 93%.
• C. Respiratory rate 18/min.
• D. Blood pressure 118/74 mm Hg.

Correct answer: A

Rationale: The correct answer is A: Heart rate 56/min. Metoprolol, a beta blocker, should be withheld if the client's heart rate is below 60/min to prevent further bradycardia. Choices B, C, and D are within normal ranges and do not indicate a need to withhold metoprolol.

3. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?

• A. HbA1c level greater than 8%.
• B. Blood glucose level greater than 200 mg/dL at bedtime.
• C. Blood glucose level less than 60 mg/dL before breakfast.
• D. HbA1c level less than 7%.

Correct answer: D

Rationale: The correct answer is D. An HbA1c level less than 7% indicates good long-term glucose control for clients with diabetes. This goal reflects optimal glycemic control and reduces the risk of long-term complications. Choices A, B, and C are incorrect because they do not represent appropriate goals for managing type 1 diabetes in an adolescent. An HbA1c level greater than 8% (choice A) signifies poor glucose control, while a blood glucose level greater than 200 mg/dL at bedtime (choice B) and a blood glucose level less than 60 mg/dL before breakfast (choice C) are not within the target ranges for safe and effective diabetes management.

4. What is the most important action when providing wound care to a client with a pressure ulcer?

• A. Apply a dry, sterile dressing to the wound
• B. Cleanse the wound with normal saline
• C. Perform a wound culture before applying ointment
• D. Cover the wound with a wet-to-dry dressing

Correct answer: C

Rationale: Performing a wound culture before applying ointment is crucial when providing wound care to a client with a pressure ulcer. This action helps identify any underlying infections, allowing healthcare providers to select the most appropriate treatment. Options A, B, and D are not as critical as performing a wound culture, as they focus on wound dressing and cleansing rather than identifying potential infections.

5. What are the risk factors for developing hypertension?

• A. High sodium diet and lack of physical activity
• B. Low potassium intake and excessive alcohol consumption
• C. Frequent exercise and low cholesterol diet
• D. Smoking and family history

Correct answer: A

Rationale: The correct answer is A: High sodium diet and lack of physical activity. These are established risk factors for developing hypertension as they contribute to elevated blood pressure. Choice B, low potassium intake and excessive alcohol consumption, may also impact blood pressure but are not as strongly associated with hypertension as high sodium intake and lack of physical activity. Choice C, frequent exercise and a low cholesterol diet, are actually beneficial for reducing the risk of hypertension. Choice D, smoking and family history, are more closely linked to other health conditions such as cardiovascular diseases, rather than being primary risk factors for hypertension.

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