Nursing Elites

1. What is an early sign that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.

2. What is an appropriate teaching point for a client with left-leg weakness learning to use a cane?

• A. Maintain two points of support on the ground at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: A

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.

3. A patient is being educated about a clear liquid diet. Which of the following should the nurse instruct the patient to avoid?

• A. Lemon-lime sports drinks
• B. Ginger ale
• C. Black coffee
• D. Orange sherbet

Correct answer: D

Rationale: The correct answer is D: Orange sherbet. A clear liquid diet consists of liquids that are transparent and easily digestible. Orange sherbet, being a frozen dessert, is not a clear liquid and should be avoided. Choices A, B, and C are all acceptable in a clear liquid diet. Lemon-lime sports drinks, ginger ale, and black coffee are clear liquids that can be included in the diet as they are transparent and leave little residue in the gastrointestinal tract, unlike orange sherbet.

4. What are the complications of untreated pneumonia?

• A. Sepsis and respiratory failure
• B. Heart failure and kidney failure
• C. Pulmonary embolism and electrolyte imbalance
• D. Liver failure and electrolyte imbalance

Correct answer: A

Rationale: The correct answer is A: Sepsis and respiratory failure. Untreated pneumonia can lead to severe complications such as sepsis, which is a life-threatening response to infection, and respiratory failure, where the lungs can no longer provide enough oxygen to the body. Heart failure and kidney failure (choice B) are not direct complications of untreated pneumonia. Pulmonary embolism and electrolyte imbalance (choice C) are also not commonly associated with untreated pneumonia. Liver failure and electrolyte imbalance (choice D) are not typical complications of pneumonia.

5. A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer?

• A. Lamb
• B. Poultry
• C. Tuna
• D. Beef

Correct answer: A

Rationale: The correct answer is A: Lamb. Lamb is high in saturated fat, which is linked to an increased risk of developing cancer. Choice B (Poultry) is a lean protein source and is not associated with an increased cancer risk. Choice C (Tuna) is a good source of omega-3 fatty acids, which have anti-inflammatory properties that may reduce cancer risk. Choice D (Beef) is also high in saturated fat like lamb, making it a poor choice for cancer prevention.

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