Nursing Elites

1. While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?

• A. Notify the operating room of a potential emergency case.
• B. No action is required at this time; this pulsation can be a normal finding in some clients.
• C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
• D. Stay with the client and ask someone else to contact the provider immediately.

Correct answer: D

Rationale: The pulsation of the tracheostomy tube with the heartbeat may indicate a tracheoinnominate artery fistula, which can lead to life-threatening hemorrhage if the artery is breached. In this scenario, as there is no active bleeding yet, the nurse should remain with the client and have another person notify the provider immediately. If the client starts to hemorrhage, the nurse should remove the tracheostomy tube and apply pressure at the bleeding site, preparing the client for urgent surgical intervention.

2. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?

• A. Increased anterior-posterior (AP) chest diameter
• B. Decreased respiratory rate
• C. Weight gain
• D. Productive cough with yellow sputum

Correct answer: A

Rationale: In COPD, the client often develops a barrel chest, characterized by an increased anterior-posterior diameter of the chest. This change is due to air trapping and hyperinflation of the lungs. Decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typically associated with COPD. Weight loss is more common due to increased work of breathing and decreased energy expenditure in individuals with COPD.

3. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?

• A. Allow family members to remain at the bedside.
• B. Ask the family if the client would like a fan in the room.
• C. Keep the television tuned to the client's favorite channel.
• D. Speak loudly to the client in case of hearing problems.

Correct answer: A

Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.

4. A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?

• A. Fremitus
• B. Hyperresonance
• C. Dullness on percussion
• D. Decreased tactile fremitus

Correct answer: C

Rationale: Pneumonia often leads to the consolidation of lung tissue, resulting in dullness on percussion. This occurs due to the presence of fluid or inflammatory material in the alveoli. Fremitus and decreased tactile fremitus are more indicative of conditions like pleural effusion or pneumothorax, where there is an increase in the density of the pleural space or air in the pleural cavity. Hyperresonance, on the other hand, is typically associated with conditions causing air trapping, such as emphysema, where there is increased air in the alveoli.

5. A client with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What should the nurse include in the teaching about this medication?

• A. Take the medication without a high-protein meal.
• B. Expect the medication to take several weeks to reach full effectiveness.
• C. The medication may cause urine to turn light.
• D. You may experience a rapid heartbeat as a common side effect.

Correct answer: B

Rationale: Patients prescribed carbidopa-levodopa should be informed that it may take several weeks for the medication to reach its full therapeutic effectiveness in managing Parkinson's disease symptoms. This delayed onset of action is important for patients to be aware of to prevent premature discontinuation of the medication due to perceived lack of efficacy.

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