Nursing Elites

1. A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

• A. Provide high-flow oxygen.
• B. Check the client for a positive Chvostek's sign.
• C. Administer an IV vasopressor medication.
• D. Monitor the client for headache.

Correct answer: A

Rationale: In this situation, the priority action is to provide high-flow oxygen to the client. Sudden onset dyspnea and severe chest pain can be indicative of a pulmonary embolism, which is a life-threatening emergency. Oxygen therapy helps improve oxygenation and stabilizes the client's condition. Checking for Chvostek's sign, administering IV vasopressors, or monitoring for a headache are not the immediate priorities in this critical situation.

2. A client is postoperative following an intermaxillary fixation due to multiple facial fractures. Which type of equipment should be at the client's bedside?

• A. Wire cutters
• B. NG tube
• C. Urinary catheter tray
• D. IV infusion pump

Correct answer: A

Rationale: In a client who has undergone intermaxillary fixation for facial fractures, wire cutters are essential equipment to have at the bedside in case of emergencies such as airway compromise. These wire cutters allow prompt removal of the wires securing the jaw if needed to ensure adequate airway patency. NG tube, urinary catheter tray, and IV infusion pump are important pieces of equipment in various clinical scenarios but are not specifically required for managing intermaxillary fixation postoperatively.

3. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?

• A. Applying suction while withdrawing the catheter
• B. Preoxygenating the client before suctioning
• C. Suctioning up to three times if necessary
• D. Suctioning for a duration of 10 to 15 seconds each time

Correct answer: A

Rationale: The correct technique for suctioning a tracheostomy involves applying suction while withdrawing the catheter to avoid damaging the tracheal mucosa. Therefore, the student applying suction while inserting the catheter indicates a need for further teaching. Preoxygenating the client, suctioning up to three times if necessary, and limiting suctioning to 10 to 15 seconds each time are all appropriate actions in tracheostomy suctioning.

4. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

5. A client is vomiting. Which of the following actions should the nurse take first?

• A. Provide the client with an emesis basin
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Administer an antiemetic to the client

Correct answer: C

Rationale: When a client is vomiting, the priority action for the nurse is to prevent the client from aspirating. Aspiration can lead to serious respiratory complications. Providing the client with an emesis basin can be helpful but preventing aspiration takes precedence. Notifying housekeeping and administering an antiemetic are secondary actions that can be addressed once the client's safety is ensured.

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