Nursing Elites

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

• A. Bradycardia
• B. Hypotension
• C. Irritability
• D. Confusion

Correct answer: C

Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.

2. A nurse is teaching a client who has irritable bowel syndrome (IBS) about dietary modifications. Which of the following instructions should the nurse include?

• A. Increase fiber intake to 35 grams per day
• B. Avoid dairy products
• C. Eat small, frequent meals
• D. Avoid fruits and vegetables

Correct answer: C

Rationale: The correct answer is C: 'Eat small, frequent meals.' Eating small, frequent meals helps manage IBS symptoms by avoiding overloading the digestive system. Choice A is incorrect because increasing fiber intake may worsen symptoms in some individuals with IBS. Choice B is not a blanket recommendation for all IBS patients; some may tolerate dairy products well. Choice D is incorrect as fruits and vegetables are important sources of nutrients and should not be completely avoided unless specific triggers are identified.

3. A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?

• A. Increased heart rate
• B. Persistent cough
• C. Constipation
• D. Sweating

Correct answer: B

Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.

4. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take to promote wound healing?

• A. Apply heat to the surgical site
• B. Ensure the client consumes adequate protein
• C. Encourage the client to ambulate frequently
• D. Instruct the client to drink 4 liters of water daily

Correct answer: B

Rationale: The correct answer is to ensure the client consumes adequate protein. Protein is essential for wound healing as it supports tissue repair. Applying heat to the surgical site (choice A) is not recommended as it can increase inflammation. Although ambulation (choice C) is beneficial for circulation and preventing complications, it is not directly related to promoting wound healing. Instructing the client to drink 4 liters of water daily (choice D) is excessive and not specifically related to wound healing in this context.

5. A client with an NG tube is experiencing nausea and a decrease in gastric secretions. What should the nurse do first?

• A. Position the client on their left side
• B. Irrigate the NG tube with sterile water
• C. Replace the NG tube with a new one
• D. Increase the suction setting to relieve the blockage

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.

Similar Questions