Nursing Elites

1. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?

• A. Movement of the trachea toward the unaffected side
• B. Bubbling of the water in the water seal chamber with exhalation
• C. Crepitus in the area above and surrounding the insertion site
• D. Eyelets not visible

Correct answer: A

Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.

2. A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?

• A. Prepare for mechanical ventilation.
• B. Administer oxygen via face mask.
• C. Prepare to administer a sedative.
• D. Assess for indications of pulmonary embolism.

Correct answer: B

Rationale: In a client with a high respiratory rate, low PaO2, and low SaO2, the priority intervention is to improve oxygenation. Administering oxygen via a face mask will help increase the oxygen supply to the client's lungs and tissues, addressing the hypoxemia. While mechanical ventilation may be necessary in severe cases, administering oxygen is the initial and most appropriate intervention to address the client's respiratory distress. Sedatives should not be given without ensuring adequate oxygenation. Assessing for pulmonary embolism is important but not the priority at this moment when the client is experiencing respiratory distress and hypoxemia.

3. A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

• A. Rest in a side-lying position after the tube is removed.
• B. Use the incentive spirometer every 4 hours after the tube is removed.
• C. Avoid speaking for extended periods.
• D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.

Correct answer: C

Rationale: It is essential to advise the client to avoid speaking for extended periods after the removal of the endotracheal tube to prevent strain on the vocal cords and allow the airway to recover. Speaking for prolonged periods can lead to irritation and potentially affect the healing process. The other options are also important post-extubation instructions, such as using the incentive spirometer to maintain lung function, positioning in a side-lying position for comfort, and frequent monitoring of vital signs to ensure the client's stability.

4. A nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?

• A. A 4-ounce steak, French fries, iceberg lettuce
• B. Baked chicken breast, broccoli, tomatoes
• C. Fried catfish, cornbread, peas
• D. Spaghetti with meat sauce, garlic bread

Correct answer: B

Rationale: The diet recommended for this client would be low in saturated fats & red meat, high in vegetables & whole grains (fiber), low in salt, & low in trans-fat. The best choice is the chicken with broccoli & tomatoes. The French fries have too much fat & the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat & no vegetables.

5. While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?

• A. Obtain a cardiology consult.
• B. Suction the client less frequently.
• C. Administer an antidysrhythmic medication.
• D. Perform pre-oxygenation prior to suctioning.

Correct answer: D

Rationale: When a client's heart rate increases and becomes irregular during suctioning of an endotracheal tube, it indicates potential hypoxemia. Performing pre-oxygenation before suctioning helps prevent hypoxemia and subsequent dysrhythmias. This intervention ensures that the client has adequate oxygen reserves before the procedure, reducing the risk of complications related to suctioning.

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