Nursing Elites

1. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?

• A. Knife fight
• B. Auto accident
• C. Sunburn
• D. Fungal infection

Correct answer: C

Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.

2. A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?

• A. Start an IV so contrast media may be given
• B. Ensure that the patient has been NPO for at least 6 hours.
• C. Inform radiology that a radioactive glucose preparation is needed
• D. Instruct the patient to undress to the waist and remove any metal objects

Correct answer: A

Rationale: For diagnosing pulmonary emboli, spiral computed tomography (CT) scans are commonly used, and contrast media may be given intravenously (IV) during the scan to enhance visualization of blood vessels. Chest x-rays are not typically diagnostic for pulmonary embolism. When preparing for a chest x-ray, the patient needs to undress and remove any metal objects. Bronchoscopy is used for examining the bronchial tree, not for assessing vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are primarily used to detect malignancies, and a radioactive glucose preparation is utilized for this purpose.

3. The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for lung cancer. Which information should the nurse include about the patient's postoperative care?

• A. Positioning on the right side
• B. Bed rest for the first 24 hours
• C. Frequent use of an incentive spirometer
• D. Chest tube placement with continuous drainage

Correct answer: C

Rationale: After a pneumonectomy, frequent deep breathing and coughing are essential to prevent atelectasis and promote gas exchange. Patients are typically positioned on the surgical side to aid in gas exchange. Early mobilization is crucial to reduce the risk of postoperative complications such as pneumonia and deep vein thrombosis. While chest tubes may or may not be placed in the surgical space, if used, they are clamped and only adjusted by the surgeon to manage serosanguineous fluid accumulation. Overfilling of the chest cavity can compromise remaining lung function and cardiovascular status. Chest x-rays are useful for monitoring fluid volume and space postoperatively. Therefore, the correct postoperative care instruction for the patient undergoing a left pneumonectomy is the frequent use of an incentive spirometer. Choices A, B, and D are incorrect as positioning on the right side, bed rest for the first 24 hours, and continuous chest tube drainage are not standard postoperative care practices for patients undergoing pneumonectomy.

4. After a bronchoscopy, what is the most appropriate intervention for a patient with a chronic cough?

• A. Elevate the head of the bed to 80 to 90 degrees.
• B. Keep the patient NPO until the gag reflex returns.
• C. Place the patient on bed rest for at least 4 hours after bronchoscopy.
• D. Notify the health care provider about blood-tinged mucus.

Correct answer: B

Rationale: The correct intervention is to keep the patient NPO until the gag reflex returns after a bronchoscopy. This is important because a local anesthetic is used during the procedure to suppress the gag and cough reflexes. Monitoring the return of these reflexes helps prevent the risk of aspiration and ensures the patient can safely resume oral intake. While blood-tinged mucus can occur after bronchoscopy, it is a common occurrence and not a cause for immediate concern. Placing the patient on bed rest for an extended period is unnecessary, and elevating the head of the bed to a high-Fowler's position is not specifically required post-bronchoscopy.

5. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

• A. Emergency pericardiocentesis
• B. Stabilization of the chest wall with tape
• C. Administration of an inhaled bronchodilator
• D. Insertion of a chest tube with a chest drainage system

Correct answer: D

Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.

Similar Questions