Nursing Elites

1. A client is admitted with a large pleural effusion. Which procedure should the nurse prepare the client for?

• A. Thoracentesis.
• B. Endotracheal intubation.
• C. Chest tube insertion.
• D. Bronchoscopy.

Correct answer: A

Rationale: Corrected Rationale: The correct procedure for a client with a large pleural effusion is thoracentesis. Thoracentesis is a diagnostic and therapeutic procedure used to remove fluid from the pleural space, which can help relieve symptoms associated with pleural effusion. Choice B (Endotracheal intubation) is incorrect as it is a procedure to secure the airway by placing a tube into the trachea. Choice C (Chest tube insertion) is incorrect as it is typically done to drain air or fluid from the pleural space over a longer period. Choice D (Bronchoscopy) is incorrect as it is a procedure used to visualize the airways and diagnose lung conditions, not specifically for pleural effusion removal.

2. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

• A. An 8-year-old living in a housing project.
• B. A 2-year-old playing on aging playground equipment.
• C. An adolescent working in a paint factory.
• D. A 10-year-old with Type 1 diabetes.

Correct answer: B

Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are more susceptible to lead poisoning from environmental sources due to their behaviors like hand-to-mouth contact and exploratory behaviors. Choices A, C, and D are less likely to be at high risk for lead poisoning compared to young children due to differences in exposure levels and behaviors related to potential sources of lead contamination.

3. During an assessment of a client with congestive heart failure, the nurse is most likely to hear which of the following upon auscultation of the heart?

• A. S3 ventricular gallop
• B. Apical click
• C. Systolic murmur
• D. Split S2

Correct answer: A

Rationale: Correct Answer: An S3 ventricular gallop is an abnormal heart sound commonly heard in clients with congestive heart failure. This sound is indicative of fluid overload or volume expansion in the ventricles, which is often present in heart failure. <br> Incorrect Answers: <br> B: An apical click is not typically associated with congestive heart failure. <br> C: A systolic murmur may be heard in various cardiac conditions but is not specific to congestive heart failure. <br> D: A split S2 refers to a normal heart sound caused by the closure of the aortic and pulmonic valves at slightly different times during inspiration, not directly related to congestive heart failure.

4. A client is admitted with ascites, malnutrition, and recent complaints of spitting up blood. What assessment finding warrants immediate intervention by the nurse?

• A. Capillary refill of 8 seconds
• B. Bruises on arms and legs
• C. Round and tight abdomen
• D. Pitting edema in lower legs

Correct answer: C

Rationale: A round and tight abdomen suggests fluid accumulation from ascites, which could signal a more severe underlying condition requiring immediate intervention. This finding indicates increased intra-abdominal pressure, which can lead to respiratory compromise or other serious complications. Capillary refill time, bruises on arms and legs, and pitting edema in the lower legs are important assessments but do not directly indicate the need for immediate intervention as a round and tight abdomen does in this case.

5. A client presents to the emergency room with an acute asthma attack. What is the nurse's priority intervention?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen at 2 liters per nasal cannula.
• C. Perform chest physiotherapy.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as prescribed. During an acute asthma attack, the priority is to open the airways quickly to help the client breathe more easily. Oxygen may be needed but bronchodilators take precedence as they directly target bronchoconstriction. Chest physiotherapy is not indicated in the acute phase of asthma and may exacerbate the condition. While emotional support is important, addressing the airway obstruction takes precedence in this situation.

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