Nursing Elites

1. A healthcare professional is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the healthcare professional to take?

• A. Hold the suction catheter with the non-dominant hand.
• B. Apply suctioning for 20 to 30 seconds.
• C. Place the catheter in a clean and dry location for later use.
• D. Use surgical asepsis when performing the procedure.

Correct answer: D

Rationale: Using surgical asepsis when performing nasal tracheal suctioning is crucial to prevent infection. Choice A is incorrect because the suction catheter should be held with the dominant hand to ensure better control and precision during the procedure. Choice B is incorrect as suctioning should be applied for no longer than 10 to 15 seconds to avoid trauma to the mucous membranes. Choice C is incorrect as the catheter should be disposed of properly after single-use to prevent cross-contamination and infection.

2. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

• A. Delegates assessment of lung sounds to nursing assistive personnel
• B. Becomes solely responsible for modifying activities of daily living
• C. Consults physical therapy for strengthening exercises in the extremities
• D. Involves respiratory therapy for altered breathing from severe anxiety levels

Correct answer: C

Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.

3. The healthcare professional is caring for a client with a chest tube. What is the most important action for the healthcare professional to take to ensure the chest tube is functioning properly?

• A. Milk the chest tube to ensure patency.
• B. Clamp the chest tube when moving the client.
• C. Ensure the water seal chamber is filled to the appropriate level.
• D. Secure the chest tube to the client's bed.

Correct answer: C

Rationale: Ensuring the water seal chamber is filled to the appropriate level is crucial to maintain the effectiveness of the chest tube drainage system. This step helps prevent air from entering the pleural space, ensuring proper lung re-expansion. 'Milking' the chest tube is not recommended as it can cause damage to the chest tube and surrounding tissues. Clamping the chest tube is not advisable as it can lead to tension pneumothorax. Securing the chest tube to the bed is important for stability but does not directly impact the functioning of the chest tube.

4. A client with chronic kidney disease is being assessed. Which laboratory value would be most concerning?

• A. Serum creatinine of 3.0 mg/dL
• B. Blood urea nitrogen (BUN) of 45 mg/dL
• C. Serum potassium of 6.5 mEq/L
• D. Hemoglobin of 10 g/dL

Correct answer: C

Rationale: In a client with chronic kidney disease, an elevated serum potassium level (hyperkalemia) is the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias due to its effect on the electrical conduction system of the heart. Monitoring and managing serum potassium levels are crucial in patients with chronic kidney disease to prevent serious complications. While elevated serum creatinine (Choice A) and Blood Urea Nitrogen (BUN) levels (Choice B) indicate impaired kidney function, hyperkalemia poses an immediate risk of cardiac complications. Hemoglobin levels (Choice D) are typically lower in chronic kidney disease due to decreased erythropoietin production, but they do not present an immediate life-threatening risk like hyperkalemia.

5. During an assessment, a nurse is evaluating the breath sounds of an adult client diagnosed with pneumonia. Which of the following actions should the nurse take?

• A. Follow a systematic pattern from side-to-side moving down the client’s chest.
• B. Ask the client to breathe in deeply through their nose.
• C. Instruct the client to sit upright with their head slightly tilted backward.
• D. Place the diaphragm of the stethoscope on the client’s chest.

Correct answer: A

Rationale: When assessing breath sounds in a client with pneumonia, the nurse should follow a systematic pattern from side-to-side moving down the client’s chest. This approach ensures a comprehensive evaluation of breath sounds across different lung fields. Asking the client to breathe in deeply through their nose (Choice B) is not necessary for assessing breath sounds. Instructing the client to sit upright with their head slightly tilted backward (Choice C) is not directly related to assessing breath sounds and may not be required. Placing the diaphragm of the stethoscope on the client’s chest (Choice D) is not the correct technique for auscultating breath sounds, as the diaphragm should be used for this purpose.

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