Nursing Elites

1. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

• A. Raise the foot of the bed to a 90� angle
• B. Remove the dressing to inspect the wound
• C. Prepare to insert a central line
• D. Administer oxygen via nasal cannula

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

2. During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?

• A. Loud wheezing
• B. Increased respiratory rate
• C. Decreased breath sounds
• D. Productive cough

Correct answer: C

Rationale: In a client experiencing an acute asthma attack, decreased breath sounds suggest severe airway obstruction or respiratory fatigue, indicating a worsening condition. Loud wheezing, increased respiratory rate, and a productive cough are common manifestations during an asthma attack as the airways constrict, leading to turbulent airflow causing wheezing, increased effort to breathe resulting in a higher respiratory rate, and mucus production causing a productive cough. However, decreased breath sounds signify a critical situation requiring immediate intervention.

3. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

• A. Initiating oxygen therapy
• B. Providing immediate rest for the client
• C. Positioning the client in high-Fowler's
• D. Administering a nebulized beta-adrenergic

Correct answer: D

Rationale: During an acute asthma exacerbation, the priority intervention is to administer a nebulized beta-adrenergic medication, such as albuterol, to help open the airways and improve breathing. This action helps address the underlying cause of the exacerbation. Oxygen therapy may be needed but is not the priority over administering the bronchodilator. Providing rest and positioning the client in high-Fowler's are important but come after administering the medication to address the immediate breathing difficulties.

4. A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?

• A. Continue to monitor the client.
• B. Immediately notify the healthcare provider.
• C. Reposition the client to the left side.
• D. Clamp the chest tube near the water seal.

Correct answer: A

Rationale: In a client with a three-chamber closed chest tube system, a rise in the water seal chamber with client inspiration is an expected finding. The nurse should continue to monitor the client as this indicates that the system is functioning correctly. There is no need to notify the healthcare provider, reposition the client, or clamp the chest tube as these actions are not indicated in response to a rise in the water seal chamber.

5. During an acute asthma attack in a client with asthma, what medication should the nurse administer first?

• A. Oral corticosteroids
• B. Short-acting beta agonist
• C. Leukotriene receptor antagonist
• D. Long-acting beta agonist

Correct answer: B

Rationale: During an acute asthma attack, the priority is to quickly relieve bronchospasm and improve breathing. Short-acting beta agonists, like albuterol, are the first-line medications as they rapidly relax bronchial muscles, providing immediate relief. Oral corticosteroids are used as adjunct therapy to reduce airway inflammation over time, while leukotriene receptor antagonists and long-acting beta agonists are not appropriate for immediate relief during an acute attack.

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