Nursing Elites

1. A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: A

Rationale: The client's shallow respirations at 9/min indicate hypoventilation, leading to an accumulation of carbon dioxide in the blood, causing respiratory acidosis. In this scenario, the client is at risk for developing respiratory acidosis due to inadequate ventilation and subsequent CO2 retention.

2. A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

• A. Pigeon
• B. Funnel
• C. Kyphotic
• D. Barrel

Correct answer: D

Rationale:

3. A healthcare professional wishes to provide client-centered care in all interactions. Which action by the healthcare professional best demonstrates this concept?

• A. Assesses for cultural influences affecting healthcare
• B. Ensures that all the client's basic needs are met
• C. Informs the client and family about all upcoming tests
• D. Thoroughly orients the client and family to the room

Correct answer: A

Rationale: Client-centered care focuses on individualizing care to meet the client's unique needs, preferences, and values. Assessing for cultural influences affecting healthcare allows the healthcare professional to provide culturally sensitive and competent care, respecting the client's beliefs and practices. It promotes effective communication, understanding, and collaboration, essential components of client-centered care.

4. A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?

• A. Clamp the tube when the client is ambulating.
• B. Keep the collection device below the level of the client's chest.
• C. Carefully coil the tubes to prevent kinking.
• D. Position the client flat to avoid leaks in the tubing.

Correct answer: B

Rationale: Keeping the collection device below the level of the client's chest ensures proper drainage and prevents backflow of fluid into the patient's chest. This position allows gravity to assist in the drainage process. Clamping the tube when the client is ambulating can cause a buildup of pressure in the chest drainage system, potentially leading to complications. Carefully coiling the tubes is important to prevent obstructions and kinks that could impede the flow of drainage. Positioning the client flat may not be ideal as it could hinder proper drainage and increase the risk of leaks in the tubing.

5. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

• A. Assess the client's lung sounds.
• B. Call the Rapid Response Team.
• C. Have the client sit upright.
• D. Listen to the client's lung sounds.

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

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