Nursing Elites

1. While caring for a client with a new tracheostomy, the nurse notices that the client is attempting to speak but is unable to. What should the nurse explain to the client regarding their inability to speak?

• A. Speaking is not possible because the tracheostomy tube blocks the vocal cords.
• B. The tracheostomy tube prevents air from reaching the vocal cords, making speech difficult.
• C. The client will regain the ability to speak once the tracheostomy tube is removed.
• D. The tracheostomy tube must be replaced with a speaking valve for the client to speak.

Correct answer: B

Rationale: The correct answer is B. The tracheostomy tube bypasses the vocal cords, preventing air from reaching them, which is necessary for speech. This makes speaking difficult but not impossible. Removing the tracheostomy tube does not automatically restore the ability to speak (choice C). While a speaking valve can be added later to allow speech, initially, the tracheostomy tube itself hinders air from reaching the vocal cords, making speech difficult (choice D is incorrect). Choice A is incorrect as the tracheostomy tube does not block the vocal cords directly; instead, it prevents air from reaching them.

2. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?

• A. The newborn is infected with an infectious blood-borne disease
• B. The newborn needs phototherapy for physiologic jaundice
• C. The mother's Rh antibodies are present in the neonatal blood
• D. The mother no longer needs Rho immune globulin injections

Correct answer: C

Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.

3. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?

• A. Apply heat to the residual limb.
• B. Administer prescribed analgesics.
• C. Elevate the residual limb.
• D. Perform range-of-motion exercises.

Correct answer: B

Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.

4. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?

• A. Due date
• B. Blood pressure
• C. Gravida and parity
• D. Fundal height

Correct answer: B

Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.

5. A client is complaining of a tingling sensation in the fingers, nose tip, and earlobes 24 hours after a total thyroidectomy. Which measure should the PN implement first?

• A. Apply sequential compression devices bilaterally
• B. Initiate prescribed L-thyroxine replacement therapy
• C. Obtain prescribed calcium gluconate for tetany
• D. Prepare for emergency tracheotomy at the bedside

Correct answer: C

Rationale: The correct answer is C: Obtain prescribed calcium gluconate for tetany. Tingling sensations post-thyroidectomy may indicate hypocalcemia, a potential complication that requires prompt treatment with calcium gluconate to prevent tetany. Initiating L-thyroxine replacement therapy (choice B) is important but not the first priority in this situation. Applying sequential compression devices (choice A) is not indicated for tingling sensations and does not address the potential complication of hypocalcemia. Preparing for an emergency tracheotomy (choice D) is not warranted based on the client's symptoms of tingling sensations.

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