Nursing Elites

1. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

• A. I have a sharp pain in my chest when I take a breath.
• B. I have been coughing up foul-tasting, brown, thick sputum.
• C. I have been sweating all day.
• D. I feel hot off and on.

Correct answer: B

Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.

2. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula

• A. Every four to six hours
• B. Continuously
• C. In a bolus
• D. Every hour

Correct answer: B

Rationale: When administering enteral feeding through a jejunostomy tube, the nurse should administer the formula continuously. Continuous feeding is essential for optimal nutrient absorption and to prevent complications. Administering the formula every four to six hours, in a bolus, or every hour may lead to inadequate nutrition, improper absorption, and an increased risk of complications such as aspiration or dumping syndrome, making these choices incorrect.

3. During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?

• A. Breath sounds are auscultated bilaterally
• B. Mist is visible in the T-Piece
• C. Pulse oximetry of 88%
• D. Client is unable to speak

Correct answer: C

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.

4. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

5. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

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