Nursing Elites

1. A healthcare provider is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the provider place at the client's bedside?

• A. Bag valve mask device
• B. Defibrillator machine
• C. Chest tube equipment
• D. Central venous catheter tray

Correct answer: A

Rationale: When a client receives a competitive neuromuscular blocking agent, it can lead to respiratory muscle paralysis. Placing a bag valve mask device at the client's bedside is crucial for providing immediate respiratory support in case of respiratory depression or failure. This device allows manual ventilation by squeezing the bag to deliver breaths to the client. The other options, such as a defibrillator machine, chest tube equipment, and central venous catheter tray, are not directly related to managing respiratory complications associated with neuromuscular blockade.

2. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

3. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?

• A. Movement of the trachea toward the unaffected side
• B. Bubbling of the water in the water seal chamber with exhalation
• C. Crepitus in the area above and surrounding the insertion site
• D. Eyelets not visible

Correct answer: A

Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.

4. A client with a tracheostomy experienced a coughing spell during a meal that was being fed by an unlicensed assistive personnel (UAP). What action by the nurse takes priority?

• A. Assess the client's lung sounds.
• B. Assign a different UAP to the client.
• C. Report the UAP to the manager.
• D. Request thicker liquids for meals.

Correct answer: A

Rationale: The priority action for the nurse is to assess the client's lung sounds to check for signs of aspiration, which can compromise the client's oxygenation. This is crucial to ensure the client's immediate safety and respiratory status. Once the client has been assessed, the nurse can then consider consulting with the registered dietitian regarding appropriate thickened liquids for future meals. Assigning a different UAP or reporting the UAP to the manager may be necessary steps but not the immediate priority in this situation.

5. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?

• A. Unequal pupils
• B. Hypertension
• C. Tympany upon chest percussion
• D. Confusion

Correct answer: D

Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.

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