Nursing Elites

1. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

• A. Administer prescribed anxiolytic medication.
• B. Ensure informed consent is on the chart.
• C. Reinforce any teaching done previously.
• D. Start the preoperative antibiotic infusion.

Correct answer: B

Rationale: The priority action for the nurse is to ensure that informed consent is on the chart. Before any surgical procedure, it is essential to have the client's informed consent documented. While administering anxiolytics, starting antibiotic infusion, and reinforcing teaching may also be necessary, obtaining informed consent takes precedence to ensure the client's understanding and agreement to proceed with the tracheostomy.

2. After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?

• A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
• B. Client's HR is 55 beats/min. Nurse withholds pain medication.
• C. Client has reduced breath sounds. Nurse calls the physician immediately.
• D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.

Correct answer: C

Rationale: After an open lung biopsy, a potential complication is pneumothorax, often indicated by reduced or absent breath sounds. The nurse should promptly notify the physician to address this serious issue and ensure timely intervention.

3. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

• A. Decreased anteroposterior chest diameter
• B. Increased breath sounds
• C. Prolonged expiratory phase
• D. Increased chest expansion

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

4. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

• A. Do you have a strong support system?
• B. What do you understand about your disease?
• C. Do you experience shortness of breath with basic activities?
• D. What medications are you prescribed to take each day?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

5. A healthcare provider collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the healthcare provider include in communications with the respiratory therapist prior to the tests? (Select ONE that does not apply)

• A. I ensured the client did not use bronchodilator medication within the specified timeframe.
• B. The client is prepared to undergo the examination in radiology.
• C. Physical therapy has approved the client for treadmill exercise.
• D. I instructed the client not to smoke for the required duration before the test.

Correct answer: C

Rationale: For accurate pulmonary function tests (PFTs), it is essential to communicate that the client did not use bronchodilators within the specified timeframe, did not smoke for the required duration before the test, and can comply with different breathing maneuvers. The use of a treadmill is not part of the PFT procedure and is unrelated to the testing process. Therefore, communicating about the client's ability to run on a treadmill is not relevant to the pulmonary function tests being conducted by the respiratory therapist.

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