Nursing Elites

1. A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

• A. Attending a class on tracheostomy care
• B. Verbally explaining all steps in the procedure
• C. Performing the procedure independently
• D. Asking relevant questions about suctioning

Correct answer: C

Rationale: When the partner can independently perform the suctioning procedure, it demonstrates a readiness for the client's discharge. This indicates that the partner has acquired the necessary skills and knowledge to provide safe care for the client at home without the direct supervision of healthcare professionals.

2. A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?

• A. Administer oxygen at 2 liters per minute via nasal cannula.
• B. Assess the client's vital signs including oxygen saturation.
• C. Notify the Rapid Response Team immediately.
• D. Place the client in a high Fowler's position.

Correct answer: D

Rationale: Placing the client in a high Fowler's position is the best action in this situation as it helps to maximize lung expansion, improve breathing, and decrease the work of breathing. This position allows for better chest expansion, improving oxygenation and ventilation for the client in respiratory distress.

3. A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

• A. Perform range-of-motion exercises
• B. Place suction equipment at the bedside
• C. Encourage the use of an incentive spirometer
• D. Administer an expectorant

Correct answer: C

Rationale: Encouraging the use of an incentive spirometer is vital in preventing pulmonary complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, promoting lung expansion, and preventing atelectasis. Range-of-motion exercises help prevent musculoskeletal complications, while placing suction equipment at the bedside is important but not directly related to preventing pulmonary complications. Administering an expectorant may help with clearing secretions but is not as effective in preventing postoperative pulmonary complications as using an incentive spirometer.

4. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?

• A. Decrease the heparin rate.
• B. Increase the heparin rate.
• C. No change to the heparin rate.
• D. Stop the heparin; start warfarin (Coumadin).

Correct answer: B

Rationale: For clients on heparin therapy, a PTT value of 1.5 to 2.5 times the normal range is required to ensure therapeutic anticoagulation. The normal PTT range is 25 to 35 seconds. In this case, the client's PTT of 25 seconds falls below the therapeutic range, indicating that the heparin dose is insufficient. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired therapeutic effect.

5. While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

• A. Atelectasis
• B. Flail chest
• C. Hemothorax
• D. Pneumothorax

Correct answer: B

Rationale: Flail chest is characterized by paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration. This occurs due to multiple rib fractures causing a segment of the chest wall to move independently from the rest of the thorax. Atelectasis refers to collapsed lung tissue, hemothorax is blood in the pleural space, and pneumothorax is air in the pleural space. In this scenario, the client's presentation aligns with the characteristic findings of flail chest.

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