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 has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?

• A. Increase the wall suction.
• B. Strip the chest tube.
• C. Clamp the chest tube.
• D. Reposition the client.

Correct answer: D

Rationale: When a client with a chest tube connected to wall suction complains of chest burning, it may indicate that the tube is irritating or compressing nearby tissues. Repositioning the client can help relieve this irritation by ensuring the tube is not kinked or pulling on the tissues. Increasing suction, stripping the tube, or clamping it are not appropriate actions and could potentially worsen the situation or cause harm.

3. A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?

• A. Blood glucose level
• B. Serum sodium level
• C. Serum calcium level
• D. Blood urea nitrogen (BUN)

Correct answer: A

Rationale: In a client presenting with a new onset of confusion, checking the blood glucose level first is crucial as hypoglycemia can cause confusion and is easily correctable. Addressing hypoglycemia promptly is essential to prevent further complications.

4. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

5. A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?

• A. Oxygen saturation of 91%
• B. Respiratory rate of 10 breaths per minute
• C. Client reports shortness of breath
• D. Use of accessory muscles

Correct answer: B

Rationale: A respiratory rate of 10 breaths per minute in a client with COPD receiving oxygen therapy may indicate respiratory depression, necessitating immediate intervention. An oxygen saturation of 91%, client reports of shortness of breath, and use of accessory muscles are expected in COPD clients.

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