Nursing Elites

1. The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?

• A. Increase the setting on the suction.
• B. Notify the provider immediately.
• C. Re-position the chest tube.
• D. Take the tubing apart to assess for clots.

Correct answer: B

Rationale: If the drainage from the chest tube decreases significantly, it may indicate a blockage by a clot, potentially leading to cardiac tamponade. The nurse's priority action should be to notify the healthcare provider immediately for further evaluation and intervention. Increasing suction, re-positioning the chest tube, or disassembling the tubing independently are not appropriate actions without healthcare provider guidance in this situation.

2. Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?

• A. Position the head of the client's bed flat
• B. Turn the client every 4 hours
• C. Brush the client's teeth with a suction toothbrush every 12 hours
• D. Provide humidity by maintaining moisture within the ventilator tubing

Correct answer: C

Rationale: Ventilator-associated pneumonia (VAP) is a common complication in clients receiving mechanical ventilation. Oral hygiene is crucial in reducing the risk of VAP. Brushing the client's teeth with a suction toothbrush every 12 hours helps prevent bacterial colonization in the oral cavity, which can be aspirated into the lungs. Positioning the head of the bed flat can increase the risk of aspiration. Turning the client every 4 hours is important for preventing pressure ulcers but not directly related to reducing VAP. Providing humidity in the ventilator tubing helps maintain airway moisture but does not directly address the risk of VAP.

3. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

• A. Administer prescribed anxiolytic medication.
• B. Ensure informed consent is on the chart.
• C. Reinforce any teaching done previously.
• D. Start the preoperative antibiotic infusion.

Correct answer: B

Rationale: The priority action for the nurse is to ensure that informed consent is on the chart. Before any surgical procedure, it is essential to have the client's informed consent documented. While administering anxiolytics, starting antibiotic infusion, and reinforcing teaching may also be necessary, obtaining informed consent takes precedence to ensure the client's understanding and agreement to proceed with the tracheostomy.

4. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

• A. Raise the foot of the bed to a 90� angle
• B. Remove the dressing to inspect the wound
• C. Prepare to insert a central line
• D. Administer oxygen via nasal cannula

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

5. When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?

• A. Insert an oral airway
• B. Administer the abdominal thrust maneuver
• C. Turn the client to the side
• D. Perform a blind finger sweep

Correct answer: B

Rationale: When a client develops an airway obstruction and remains conscious, the nurse's initial action should be to administer the abdominal thrust maneuver. This technique, also known as the Heimlich maneuver, can help dislodge the obstructing object and clear the airway. Inserting an oral airway, turning the client to the side, or performing a blind finger sweep are not recommended as the first interventions for a conscious individual with an airway obstruction.

Similar Questions