Nursing Elites

1. A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?

• A. Bradycardia
• B. Bradypnea
• C. Lethargy
• D. Intercostal retractions

Correct answer: D

Rationale: Postoperative atelectasis can lead to hypoxia, which causes respiratory distress. Intercostal retractions, where the muscles between the ribs pull inward during inspiration, are a common sign of respiratory distress in a client with atelectasis. Bradycardia (slow heart rate), Bradypnea (slow breathing rate), and lethargy are not typically associated with atelectasis and hypoxia.

2. When interviewing a client recently diagnosed with lung cancer and having a 60-pack-year smoking history, what is the most important action for the nurse to take?

• A. Educate the client about the importance of quitting smoking to halt cancer progression.
• B. Encourage the client to disclose both tobacco and marijuana use openly.
• C. Maintain a nonjudgmental attitude to promote honest communication with the client.
• D. Provide realistic information about cancer treatment and prognosis without giving false hope.

Correct answer: C

Rationale: Maintaining a nonjudgmental attitude during the interview is crucial to create a safe environment where the client feels comfortable and open about disclosing their smoking history and other relevant information. This approach helps establish trust and facilitates an honest conversation which is essential for providing appropriate care and support to the client.

3. 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.

4. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

• A. Pain severity
• B. Wound drainage
• C. Tissue integrity
• D. Airway patency

Correct answer: D

Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.

5. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?

• A. Assess the client's oxygen saturation.
• B. Notify the Rapid Response Team.
• C. Oxygenate the client with a bag-valve-mask.
• D. Palpate the skin of the upper chest.

Correct answer: A

Rationale: In this scenario, the client may have subcutaneous emphysema, where air leaks into the tissues surrounding the tracheostomy. The priority action for the nurse is to assess the client's oxygen saturation and other indicators of oxygenation to ensure adequate oxygen supply. If the client is stable, the nurse can then proceed to palpate the skin of the upper chest to check for subcutaneous emphysema. If the client is unstable, the nurse should promptly notify the Rapid Response Team. Using a bag-valve-mask device may be necessary for oxygenating the client, but assessing oxygen saturation comes first to guide further interventions.

Similar Questions