Nursing Elites

1. A client with a history of stroke presents with dysphagia. What is the most important nursing intervention to prevent aspiration?

• A. Encourage the client to drink water between meals
• B. Position the client in a high-Fowler's position during meals
• C. Provide the client with thickened liquids
• D. Allow the client to eat quickly

Correct answer: B

Rationale: The correct answer is B: Position the client in a high-Fowler's position during meals. Placing the client in a high-Fowler's position (sitting upright at a 90-degree angle) helps reduce the risk of aspiration by ensuring that the airway is protected during swallowing. This position facilitates easier swallowing and decreases the likelihood of food or liquids entering the respiratory tract. Encouraging the client to drink water between meals (choice A) does not directly address the risk of aspiration during meals. Providing thickened liquids (choice C) may be necessary for some patients with dysphagia but is not the most important intervention to prevent aspiration. Allowing the client to eat quickly (choice D) without proper positioning and precautions can increase the risk of aspiration.

2. What is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft?

• A. Monitor for signs of infection
• B. Ensure the client is pain-free
• C. Assess for bleeding and arrhythmias
• D. Maintain a patent airway

Correct answer: D

Rationale: Maintaining a patent airway is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft. This is crucial to ensure adequate oxygenation, especially in the early recovery phase. Monitoring for signs of infection, ensuring the client is pain-free, and assessing for bleeding and arrhythmias are important aspects of postoperative care but maintaining a clear airway takes precedence in this scenario to prevent hypoxia and respiratory compromise. In the immediate postoperative period, maintaining a patent airway is essential to prevent complications such as airway obstruction, hypoxia, and respiratory distress, which are critical in ensuring the client's safety and recovery.

3. A postoperative client complains of sudden shortness of breath. What should the nurse do first?

• A. Administer oxygen
• B. Call the healthcare provider
• C. Prepare for chest x-ray
• D. Assess the client's lung sounds

Correct answer: D

Rationale: Assessing the client's lung sounds is the most appropriate initial action when a postoperative client complains of sudden shortness of breath. This step helps the nurse evaluate the respiratory status and detect abnormalities such as decreased breath sounds or crackles, which could indicate a serious condition like a pulmonary embolism. Administering oxygen (Choice A) may be necessary but should come after assessing the lung sounds to ensure the appropriate intervention. Calling the healthcare provider (Choice B) or preparing for a chest x-ray (Choice C) can be important subsequent actions based on the findings from the lung sound assessment, but they are not the first priority in this situation.

4. A client undergoing chemotherapy reports a sudden onset of severe back pain. What should the nurse do first?

• A. Administer pain medication as prescribed
• B. Assess the pain's nature and intensity
• C. Encourage the client to rest and apply a hot pack
• D. Notify the physician immediately

Correct answer: B

Rationale: The correct first action for the nurse is to assess the nature and intensity of the pain. This initial assessment is crucial in determining the underlying cause of the pain, whether it is related to the chemotherapy or another issue. Understanding the pain's characteristics will guide the nurse in implementing appropriate interventions and seeking timely medical assistance if needed. Administering pain medication without a thorough assessment may mask important symptoms and delay necessary treatment. Encouraging rest and hot pack application may be appropriate interventions but should come after assessing the pain. Notifying the physician immediately can be important but should follow the initial assessment to provide comprehensive information to the healthcare provider.

5. A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

• A. Increase wall suction to eliminate fluctuation in the water seal.
• B. Give blood from the collection chamber as autotransfusion.
• C. Add sterile water to the suction control chamber.
• D. Manipulate blood in tubing to drain into chamber.

Correct answer: C

Rationale: The correct intervention for the nurse to implement is to add sterile water to the suction control chamber. This action helps maintain the proper functioning of the chest tube system by regulating the negative pressure. Increasing wall suction is not recommended as it could lead to excessive negative pressure. Giving blood from the collection chamber as autotransfusion is inappropriate and poses a risk of complications such as air embolism. Manipulating blood in the tubing is also unsafe as it could introduce air into the system, increasing the risk of complications for the client.

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