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 is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

• A. Supine with head elevated
• B. Lateral recumbent
• C. Prone with arms at sides
• D. Sitting with back rounded

Correct answer: B

Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.

3. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

4. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

• A. Canned soup
• B. Grilled chicken
• C. Peanut butter
• D. Orange juice

Correct answer: B

Rationale: Grilled chicken is the correct choice as it is a low-potassium, low-sodium option suitable for clients with chronic kidney disease. Canned soup (choice A) is typically high in sodium, which is not recommended for this client population. Peanut butter (choice C) is high in potassium and phosphorus, which should be limited in individuals with kidney disease. Orange juice (choice D) is high in potassium and should be consumed in moderation by clients with chronic kidney disease.

5. What should be included in dietary teaching for a client with chronic kidney disease?

• A. Increase potassium-rich foods in the diet
• B. Limit phosphorus and potassium intake
• C. Encourage protein-rich foods to improve nutrition
• D. Increase calcium-rich foods in the diet

Correct answer: B

Rationale: The correct answer is to limit phosphorus and potassium intake for a client with chronic kidney disease. In renal insufficiency, the kidneys struggle to excrete these minerals, leading to their buildup in the blood, which can be harmful. Limiting phosphorus and potassium intake helps prevent further kidney damage and manage the progression of chronic kidney disease. Encouraging protein-rich foods (Choice C) may be counterproductive as excessive protein intake can burden the kidneys. Increasing potassium-rich foods (Choice A) is incorrect as high potassium levels can be detrimental in kidney disease. Increasing calcium-rich foods (Choice D) is not typically a focus in dietary teaching for chronic kidney disease unless there is a specific deficiency or need, as excessive calcium intake can also be harmful to kidney function.

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