Nursing Elites

1. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?

• A. Bring a list of all medications and their purposes.
• B. Keep the doctor's phone number close by.
• C. Ensure all providers wash their hands before entering the room.
• D. Document the name of each caregiver who enters the room.

Correct answer: A

Rationale: The most important action a client can take to protect against errors is to bring a list of all medications and their purposes. This helps ensure that the healthcare team has accurate information about the client's medications, reducing the risk of medication errors, which are the most common type of healthcare mistake. Knowing the medications and their purposes can also aid in preventing drug interactions and adverse effects during the surgical procedure.

2. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

• A. Evaluate chest expansion.
• B. Check pupillary response to light.
• C. Assess the capillary refill.
• D. Check the client's response to questions about place and time.

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

3. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

• A. Elevate the head of the client's bed.
• B. Measure and compare cuff pressures.
• C. Place the client on NPO status.
• D. Request a swallow study for the client.

Correct answer: B

Rationale: When food particles are noted during suctioning of a client with a tracheostomy tube, it can indicate tracheomalacia due to constant pressure from the tracheostomy cuff. This condition may lead to dilation of the tracheal passage. To address this issue, the nurse should measure and compare cuff pressures. By monitoring these pressures and comparing them to previous readings, the nurse can identify trends and potential complications. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not directly address the cuff pressure issue causing food particles in the secretions.

4. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding does the nurse expect?

• A. Increased anteroposterior (AP) chest diameter
• B. Decreased respiratory rate
• C. Weight gain
• D. Productive cough with yellow sputum

Correct answer: A

Rationale: Clients with COPD commonly develop a barrel chest, characterized by an increased anteroposterior diameter of the chest. This change is due to chronic air trapping and hyperinflation of the lungs. A decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typical findings in COPD. Instead, COPD patients often present with an increased respiratory rate, weight loss, and a chronic cough with sputum production.

5. A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?

• A. Fremitus
• B. Hyperresonance
• C. Dullness on percussion
• D. Decreased tactile fremitus

Correct answer: C

Rationale: Pneumonia often leads to the consolidation of lung tissue, resulting in dullness on percussion. This occurs due to the presence of fluid or inflammatory material in the alveoli. Fremitus and decreased tactile fremitus are more indicative of conditions like pleural effusion or pneumothorax, where there is an increase in the density of the pleural space or air in the pleural cavity. Hyperresonance, on the other hand, is typically associated with conditions causing air trapping, such as emphysema, where there is increased air in the alveoli.

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