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. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

• A. Evaluate chest expansion.
• B. Check pupillary response to light.
• C. Assess the capillary refill.
• D. Check the client's response to questions about place and time.

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

3. A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

• A. Administer prescribed salmeterol (Serevent) inhaler.
• B. Assess the client for a tracheal deviation.
• C. Administer oxygen to maintain saturations above 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation suggests the client is using accessory muscles due to difficulty in moving air into the respiratory passages caused by airway narrowing. The presence of bilateral wheezing and decreased pulse oxygen saturation further support airway narrowing. In this situation, immediate intervention is necessary to improve oxygenation. Administering oxygen to maintain saturations above 94% is crucial to support oxygenation. While administering a rescue inhaler may be warranted, the priority in this scenario is ensuring adequate oxygenation to address the respiratory distress.

4. A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?

• A. Arterial blood gases
• B. Urinary output
• C. Chest tube drainage
• D. Pain level

Correct answer: A

Rationale: Arterial blood gases are crucial to assess postoperatively in a client who has undergone thoracotomy and lobectomy to monitor oxygenation and ventilation status. Changes in arterial blood gases can indicate respiratory complications or inadequate gas exchange, which are critical issues that need prompt intervention to prevent further complications. While urinary output, chest tube drainage, and pain level are important assessments, monitoring arterial blood gases takes precedence in this specific postoperative scenario to ensure optimal respiratory function and overall patient well-being.

5. A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?

• A. I plan to wear my oxygen when I exercise & feel short of breath.
• B. I will use my portable oxygen when grilling burgers in the backyard.
• C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
• D. I will only smoke while I am wearing my oxygen via nasal cannula.

Correct answer: C

Rationale: Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling & smoking increases the risk for fire.

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