Nursing Elites

1. 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.

2. The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?

• A. Explain the importance of using the inhaler daily to prevent asthma attacks.
• B. Suggest identifying community services to help with the cost and encourage daily use of the inhaler.
• C. Explore the client's fears regarding breathlessness.
• D. Emphasize the necessity of using this inhaler daily and discuss potential community services for financial assistance.

Correct answer: B

Rationale: The correct response should address the client's concern about the cost of using the inhaler daily. While emphasizing the importance of daily use is crucial, it is also essential to acknowledge and offer support for the financial burden. Identifying community resources can help the client access affordable medications. Exploring fears related to breathlessness does not directly address the client's financial concerns.

3. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

• A. Oxygen saturation of 95%
• B. No fluctuations in the water seal chamber
• C. No reports of pleuritic chest pain
• D. Occasional bubbling in the water-seal chamber

Correct answer: B

Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.

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 who will undergo a bronchoscopy procedure with a rigid scope and general anesthesia will have their neck in which of the following positions?

• A. A flexed position
• B. An extended position
• C. A neutral position
• D. A hyperextended position

Correct answer: D

Rationale: During a bronchoscopy with a rigid scope and general anesthesia, the provider will typically place the client's neck in a hyperextended position to allow better visualization and access to the airways. This position helps to align the trachea for easier insertion of the scope.

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