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 healthcare provider collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the healthcare provider include in communications with the respiratory therapist prior to the tests? (Select ONE that does not apply)

• A. I ensured the client did not use bronchodilator medication within the specified timeframe.
• B. The client is prepared to undergo the examination in radiology.
• C. Physical therapy has approved the client for treadmill exercise.
• D. I instructed the client not to smoke for the required duration before the test.

Correct answer: C

Rationale: For accurate pulmonary function tests (PFTs), it is essential to communicate that the client did not use bronchodilators within the specified timeframe, did not smoke for the required duration before the test, and can comply with different breathing maneuvers. The use of a treadmill is not part of the PFT procedure and is unrelated to the testing process. Therefore, communicating about the client's ability to run on a treadmill is not relevant to the pulmonary function tests being conducted by the respiratory therapist.

3. In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?

• A. Airway protection
• B. Decreasing intracranial pressure
• C. Stabilizing cardiac arrhythmias
• D. Preventing musculoskeletal disability

Correct answer: A

Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.

4. A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?

• A. Chest tube eyelets not visible
• B. Continuous bubbling in the suction control chamber
• C. Presence of tidal fluctuation in the water seal chamber
• D. Development of subcutaneous emphysema

Correct answer: D

Rationale: The development of subcutaneous emphysema is a concerning finding that requires immediate intervention. Subcutaneous emphysema results from air leaking into the tissues, which can lead to respiratory compromise. It is important to address this issue promptly to prevent further complications. The other options are normal or expected findings in a chest tube drainage system. Chest tube eyelets not being visible may indicate dislodgement, continuous bubbling in the suction control chamber indicates proper functioning, and the presence of tidal fluctuation in the water seal chamber demonstrates appropriate drainage and lung re-expansion.

5. A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?

• A. Administer pain medication as ordered.
• B. Check the client's blood pressure.
• C. Place the client in a supine position.
• D. Increase the client's fluid intake.

Correct answer: B

Rationale: The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.

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