Nursing Elites

1. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

• A. Night sweats
• B. Low-grade fever
• C. Weight gain
• D. Blood in the sputum

Correct answer: C

Rationale:

2. What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?

• A. Are you taking any medications or herbal supplements?
• B. Do you have any chronic breathing problems?
• C. How often do you perform aerobic exercise?
• D. What is your occupation and what are your hobbies?

Correct answer: B

Rationale: The correct answer is B. A nurse should ask the client if they have any chronic breathing problems when the anteroposterior (AP) chest diameter is the same as the lateral chest diameter. This finding indicates a barrel chest, which can be associated with chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) or emphysema. Assessing for chronic breathing problems can help the nurse further evaluate the client's respiratory status and provide appropriate care.

3. A healthcare professional is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the professional expect to hear?

• A. Loud, scratchy sounds
• B. Squeaky, musical sounds
• C. Popping sounds
• D. Snoring sounds

Correct answer: A

Rationale: When auscultating the lungs of a client with pleurisy, the healthcare professional should expect to hear loud, scratchy sounds. These sounds are characteristic of pleurisy, which is an inflammation of the pleura, causing a rough, grating sound during breathing.

4. While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

• A. Atelectasis
• B. Flail chest
• C. Hemothorax
• D. Pneumothorax

Correct answer: B

Rationale: Flail chest is characterized by paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration. This occurs due to multiple rib fractures causing a segment of the chest wall to move independently from the rest of the thorax. Atelectasis refers to collapsed lung tissue, hemothorax is blood in the pleural space, and pneumothorax is air in the pleural space. In this scenario, the client's presentation aligns with the characteristic findings of flail chest.

5. A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)

• A. Administer prescribed albuterol (Ventolin) inhaler.
• B. Assess the client for tracheal deviation.
• C. Administer oxygen to maintain saturations greater than 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation indicates the use of accessory muscles and difficulty in moving air due to airway narrowing, supported by bilateral wheezing and decreased pulse oxygen saturation. This client needs immediate intervention as their asthma is not responding to the medication. Administering oxygen to maintain saturations above 94% is crucial to ensure adequate oxygenation. While administering a rescue inhaler could also be necessary, oxygen therapy takes priority in this situation.

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