Nursing Elites

1. A client is admitted with a large pleural effusion. Which procedure should the nurse prepare the client for?

• A. Thoracentesis.
• B. Endotracheal intubation.
• C. Chest tube insertion.
• D. Bronchoscopy.

Correct answer: A

Rationale: Corrected Rationale: The correct procedure for a client with a large pleural effusion is thoracentesis. Thoracentesis is a diagnostic and therapeutic procedure used to remove fluid from the pleural space, which can help relieve symptoms associated with pleural effusion. Choice B (Endotracheal intubation) is incorrect as it is a procedure to secure the airway by placing a tube into the trachea. Choice C (Chest tube insertion) is incorrect as it is typically done to drain air or fluid from the pleural space over a longer period. Choice D (Bronchoscopy) is incorrect as it is a procedure used to visualize the airways and diagnose lung conditions, not specifically for pleural effusion removal.

2. A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?

• A. Multiple firm, round, freely movable masses.
• B. A slight asymmetry of the breasts.
• C. A fixed nodular mass with dimpling of the skin.
• D. Bloody discharge from the nipple.

Correct answer: C

Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.

3. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

4. A client with chronic obstructive pulmonary disease (COPD) is experiencing difficulty breathing. What is the nurse's priority intervention?

• A. Administer a bronchodilator via nebulizer.
• B. Increase the client's oxygen flow rate.
• C. Elevate the head of the bed.
• D. Reposition the client to a side-lying position.

Correct answer: B

Rationale: In clients with COPD experiencing difficulty breathing, increasing the client's oxygen flow rate is the priority intervention. This action helps to improve oxygenation and relieve shortness of breath. While bronchodilators and other medications may be necessary, providing immediate oxygen support is crucial. Elevating the head of the bed and repositioning the client can assist with breathing comfort but do not address the immediate need for improved oxygenation in COPD exacerbation.

5. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

• A. Assess the client’s skin for lesions or sores.
• B. Monitor the client’s liver function tests.
• C. Assess for changes in mental status and behavior.
• D. Monitor the client’s urine output closely.

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

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