Nursing Elites

1. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

• A. Oxygen saturation of 95%
• B. No fluctuations in the water seal chamber
• C. No reports of pleuritic chest pain
• D. Occasional bubbling in the water-seal chamber

Correct answer: B

Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.

2. 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.

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. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

• A. Administer prescribed anxiolytic medication.
• B. Ensure informed consent is on the chart.
• C. Reinforce any teaching done previously.
• D. Start the preoperative antibiotic infusion.

Correct answer: B

Rationale: The priority action for the nurse is to ensure that informed consent is on the chart. Before any surgical procedure, it is essential to have the client's informed consent documented. While administering anxiolytics, starting antibiotic infusion, and reinforcing teaching may also be necessary, obtaining informed consent takes precedence to ensure the client's understanding and agreement to proceed with the tracheostomy.

5. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

• A. Withhold food and liquids until the client's gag reflex returns.
• B. Irrigate the client's throat every 4 hours.
• C. Have the client refrain from talking for 24 hours.
• D. Suction the client's oropharynx frequently.

Correct answer: A

Rationale: After a flexible bronchoscopy, it is crucial to withhold food and liquids until the client's gag reflex returns to prevent aspiration. Irrigating the client's throat every 4 hours, having the client refrain from talking for 24 hours, and frequent suctioning of the oropharynx are not indicated post-bronchoscopy and may even pose risks to the client's recovery.

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