Nursing Elites

1. One hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on a 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?

• A. Milk the chest tube gently to remove any clots.
• B. Clamp the chest tube momentarily to check for the origin of the air leak.
• C. Assist the patient to deep breathe, cough, and use the incentive spirometer.
• D. Set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine.

Correct answer: S

Rationale: In this scenario, the best action is to set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine. The patient's pain level is high, which can hinder deep breathing and coughing. Addressing pain control is a priority to facilitate optimal respiratory function. Milking the chest tube to remove clots is unnecessary as the drainage amount is not alarming in the early postoperative period. Clamping the chest tube to locate the air leak is not recommended as it can lead to tension pneumothorax. Assisting the patient to deep breathe, cough, and use the incentive spirometer is important but should follow adequate pain management to ensure the patient can effectively participate in these activities.

2. A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?

• A. Slow, deep respirations
• B. Stridor
• C. Bradycardia
• D. Air hunger

Correct answer: D

Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (Choice A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (Choice B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (Choice C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.

3. The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document?

• A. 14
• B. 16
• C. 17
• D. 28

Correct answer: B

Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. The nurse counted eight respirations over 30 seconds, so doubling this count gives a respiratory rate of 16 breaths per minute. This calculation is based on the assumption that the client's breathing pattern remained relatively stable during the two 30-second intervals. Options A, C, and D are incorrect because they do not reflect the accurate count obtained without interruptions. Choice B (16) is the correct answer as it reflects the uninterrupted count of respirations by the nurse.

4. A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder?

• A. It is an acute bowel obstruction.
• B. It is a condition that causes an acute inflammatory process in the bowel.
• C. It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel.
• D. It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel.

Correct answer: D

Rationale: Intussusception is a condition in which a proximal segment of the bowel telescopes or prolapses into a distal segment of the bowel. This leads to bowel obstruction and potential ischemia. It is not an acute bowel obstruction, as the obstruction is caused by the telescoping of bowel segments rather than a blockage in the bowel lumen. Intussusception is not primarily an inflammatory process; instead, it is a mechanical issue involving bowel invagination. Choice A is incorrect as it does not accurately describe the pathophysiology of intussusception. Choice C is incorrect because it presents the opposite scenario of what happens in intussusception.

5. Which of the following statements best describes postural drainage as part of chest physiotherapy?

• A. Tapping on the chest wall to loosen secretions
• B. Squeezing the abdomen to increase expansion of the upper chest
• C. Using gravity to move secretions in the lung tissue
• D. Dilating the trachea to facilitate better release of secretions

Correct answer: C

Rationale: Postural drainage is a technique used in chest physiotherapy for clients with accumulated lung secretions. It involves positioning the client to utilize gravity in moving secretions from the lungs. Choice A, tapping on the chest wall, describes percussion, not postural drainage. Choice B, squeezing the abdomen, is not a correct description of postural drainage. Choice D, dilating the trachea, is not related to postural drainage but may be associated with airway clearance techniques.

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