Nursing Elites

1. While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?

• A. Airway obstruction
• B. Infection
• C. Fluid imbalance
• D. Paralytic ileus

Correct answer: A

Rationale: When a client sustains burns to the head, neck, or chest, the risk of airway obstruction is a critical concern due to potential swelling, inflammation, or inhalation injury. Any compromise to the airway can lead to severe respiratory distress or failure. Early recognition and intervention to maintain a clear airway are essential to prevent life-threatening complications in burn patients.

2. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

• A. Check the tubing connections for leaks.
• B. Check the suction control outlet on the wall.
• C. Clamp the chest tube.
• D. Continue to monitor the client's respiratory status.

Correct answer: A

Rationale: In a closed chest drainage system, slow, steady bubbling in the suction control chamber is an expected finding, indicating proper functioning of the system. There is no immediate need for intervention as this indicates the system is working as intended. The nurse should continue to monitor the client's respiratory status for any signs of distress or changes. Checking tubing connections for leaks or clamping the chest tube are unnecessary actions based on the information provided. Checking the suction control outlet on the wall is also not indicated in this scenario.

3. A healthcare professional is interested in making interdisciplinary work a high priority. Which actions by the professional best demonstrate this skill? (Select ONE that does not apply)

• A. Consulting with other disciplines on client care
• B. Coordinating discharge planning for home safety
• C. Participating in comprehensive client rounding
• D. Sharing the care plans with other disciplines

Correct answer: B

Rationale: Interdisciplinary work in healthcare involves effective communication and collaboration between different disciplines for holistic client care. Consulting with other disciplines allows for sharing expertise, insights, and perspectives to enhance client outcomes. Participating in comprehensive client rounding involves a team-based approach to discuss and plan client care collectively. Sharing nursing care plans with other disciplines ensures that all team members are informed and can contribute to the client's overall well-being. Coordinating discharge planning is important but may not directly demonstrate interdisciplinary collaboration as the other actions do.

4. When planning care, what factors should the nurse consider when utilizing evidence-based practice (EBP)? (Select ONE that does not apply)

• A. Cost-saving measures
• B. Nurse's expertise
• C. Client preferences
• D. Research findings

Correct answer: A

Rationale: In evidence-based practice (EBP), nurses should consider the current evidence (research findings), client preferences, and the nurse's expertise when planning care. By integrating these factors, nurses can provide individualized, effective, and patient-centered care that aligns with the best available evidence, the patient's values, and the nurse's clinical knowledge and experience.

5. Prior to a thoracentesis, what intervention should the nurse complete?

• A. Measure oxygen saturation before and after the procedure.
• B. Verify that the client has given informed consent.
• C. Explain the procedure briefly to the client and their family.
• D. Ensure informed consent has been obtained from the client.

Correct answer: D

Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.

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