Nursing Elites

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

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

Correct answer: B

Rationale: Irritability is an early sign that suctioning is necessary to clear the airway in a client with a tracheostomy. When secretions build up in the tracheostomy tube, the client may become irritable due to the discomfort and the compromised airway. Bradycardia, confusion, and hypotension are not typically early signs that suctioning is required. Bradycardia may occur if the airway becomes severely compromised, confusion may be a late sign of hypoxia, and hypotension is not directly related to the need for suctioning in a client with a tracheostomy.

2. A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?

• A. The client's urination habits.
• B. The client's financial information.
• C. The client's social history.
• D. The client's current level of mobility.

Correct answer: D

Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.

3. A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

• A. Keep the client awake
• B. Instruct the client not to get out of bed
• C. Encourage the client to drink fluids
• D. Encourage early ambulation

Correct answer: B

Rationale: The correct answer is to instruct the client not to get out of bed. Lorazepam is a sedative that can cause drowsiness and impair coordination. By instructing the client not to get out of bed, the nurse helps prevent falls or injuries that could occur due to the medication's sedative effects. Choice A is incorrect as keeping the client awake may not be necessary and could lead to unnecessary discomfort. Choice C is incorrect as encouraging the client to drink fluids is not directly related to the administration of lorazepam. Choice D is incorrect as early ambulation is not safe immediately after administering a sedative medication.

4. A client with left-leg weakness is learning to use a cane. Which teaching point is most appropriate?

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

Correct answer: B

Rationale: The correct teaching point is to maintain two points of support on the ground at all times when using a cane. This ensures stability and helps distribute weight evenly. Choice A is incorrect because the cane should be used on the stronger side of the body to provide support to the weaker leg. Choice C is incorrect as advancing the cane too far with each step can lead to imbalance. Choice D is incorrect as advancing the cane and the strong leg simultaneously may not provide adequate support for the weaker leg.

5. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

• A. Administer insulin
• B. Administer glucagon
• C. Administer 4 oz of orange juice
• D. Administer 1 L of water

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.

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