Nursing Elites

1. Prior to a thoracentesis, what intervention should the nurse complete?

• A. Measure oxygen saturation before and after the procedure.
• B. Verify that the client has given informed consent.
• C. Explain the procedure briefly to the client and their family.
• D. Ensure informed consent has been obtained from the client.

Correct answer: D

Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.

2. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

• A. Elevate the head of the client's bed.
• B. Measure and compare cuff pressures.
• C. Place the client on NPO status.
• D. Request a swallow study for the client.

Correct answer: B

Rationale: When food particles are noted during suctioning of a client with a tracheostomy tube, it can indicate tracheomalacia due to constant pressure from the tracheostomy cuff. This condition may lead to dilation of the tracheal passage. To address this issue, the nurse should measure and compare cuff pressures. By monitoring these pressures and comparing them to previous readings, the nurse can identify trends and potential complications. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not directly address the cuff pressure issue causing food particles in the secretions.

3. During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?

• A. Nausea
• B. Dysphagia
• C. Agitation
• D. Hypotension

Correct answer: C

Rationale: During an asthma attack, hypoxemia can lead to inadequate oxygen supply to the brain, causing symptoms like restlessness, confusion, and agitation. These manifestations result from the body's response to low oxygen levels, aiming to increase oxygenation. Nausea, dysphagia, and hypotension are not typical manifestations of hypoxemia during an asthma attack.

4. A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?

• A. Stridor
• B. Copious oral secretions
• C. Hoarseness
• D. Sore throat

Correct answer: A

Rationale: Stridor is a high-pitched, harsh respiratory sound that can indicate airway obstruction. It is a serious finding that requires immediate attention as it may lead to respiratory compromise. Copious oral secretions, hoarseness, and sore throat are common but expected findings after endotracheal tube removal and do not typically require urgent intervention.

5. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

• A. Do you have a strong support system?
• B. What do you understand about your disease?
• C. Do you experience shortness of breath with basic activities?
• D. What medications are you prescribed to take each day?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

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