Nursing Elites

1. The nurse notes that a client who has undergone a thoracotomy has an increase in a large amount of dark red blood in the chest tube collection chamber. What action should the nurse take?

• A. Document the findings for this procedure as expected
• B. Notify the healthcare provider immediately
• C. Check the tube for kinks or dependent loops
• D. Increase the suction to the chest drainage system

Correct answer: B

Rationale: An increase in a large amount of dark red blood in the chest tube collection chamber may indicate active bleeding. The nurse should notify the healthcare provider immediately to address the situation promptly and prevent further complications. Documenting the findings without taking immediate action could delay necessary interventions. Checking the tube for kinks or dependent loops is a good practice but not the priority when dealing with a potentially life-threatening situation like active bleeding. Increasing the suction without healthcare provider's orders can lead to complications and is not appropriate in this scenario.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?

• A. Barrel-shaped chest
• B. Use of accessory muscles
• C. Oxygen saturation of 85%
• D. Inspiratory crackles

Correct answer: C

Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.

3. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

• A. Digitally check the client for a fecal impaction
• B. Administer a laxative to stimulate bowel movement
• C. Increase fluid intake to soften stool
• D. Perform a digital rectal examination

Correct answer: A

Rationale: The correct action for the nurse to implement is to digitally check the client for a fecal impaction. In this scenario, the client's presentation of frequent small amounts of liquid stool after a period of no bowel movement suggests a possible impaction. By performing a digital examination, the nurse can assess for the presence of a blockage that may be causing the symptoms. Administering a laxative (Choice B) without assessing for impaction can worsen the situation. Increasing fluid intake (Choice C) is generally beneficial for bowel health but may not address the immediate issue of a potential impaction. Performing a digital rectal examination (Choice D) is similar to Choice A but is more focused on assessing the rectum itself rather than checking for an impaction.

4. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure. Immediate intervention is necessary to prevent further deterioration of the respiratory status. Choice A, an oxygen saturation of 90%, though low, may not require immediate intervention as it is above the typical threshold for initiating supplemental oxygen. Choice B, a respiratory rate of 24 breaths per minute, falls within the normal range for an adult and may not be an immediate cause for concern. Choice D, inspiratory crackles, are indicative of fluid in the lungs but may not require immediate intervention unless accompanied by other concerning signs like decreased oxygen saturation or increased respiratory distress.

5. A client with hyperthyroidism is admitted to the postoperative unit after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Total calcium 5.0 mg/dL.
• B. Serum sodium 140 mEq/L.
• C. Serum potassium 4.0 mEq/L.
• D. Serum glucose 90 mg/dL.

Correct answer: A

Rationale: The correct answer is A. A calcium level of 5.0 mg/dL is critically low and could indicate hypoparathyroidism, a possible complication after thyroidectomy. Low calcium levels can lead to tetany, seizures, and cardiac dysrhythmias, requiring immediate intervention. Choices B, C, and D fall within the normal range and do not require immediate intervention in this scenario.

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