Nursing Elites

1. A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)

• A. Production of pink sputum
• B. Tracheal deviation
• C. Pain at insertion site
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is necessary when a client with a mediastinal chest tube exhibits tracheal deviation since it may indicate a tension pneumothorax. This condition requires prompt attention to prevent serious complications. While the production of pink sputum and pain at the insertion site should be monitored and reported, they do not typically require immediate intervention. Sudden onset of shortness of breath could indicate various issues related to the chest tube but is not as critical as tracheal deviation in this context.

2. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• A. Breathing so rapidly interferes with oxygenation.
• B. Maybe the client has respiratory distress syndrome.
• C. The blood clot interferes with perfusion in the lungs.
• D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

3. When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?

• A. Attending to holistic client needs
• B. Ensuring client safety
• C. Avoiding medication errors
• D. Providing client-focused care

Correct answer: B

Rationale: The priority for a nurse working on an inpatient medical-surgical unit is to ensure client safety. This is crucial as errors in hospital care can lead to preventable deaths. While attending to holistic client needs and providing client-focused care are important aspects of nursing, ensuring client safety takes precedence to prevent harm and promote positive patient outcomes.

4. A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?

• A. Administer pain medication as ordered.
• B. Check the client's blood pressure.
• C. Place the client in a supine position.
• D. Increase the client's fluid intake.

Correct answer: B

Rationale: The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.

5. A client interested in smoking cessation is being taught by a nurse. Which statements should the nurse include in the teaching? (Select one that does not apply)

• A. Find an activity that you enjoy and will keep your hands busy.
• B. Keep snacks like potato chips on hand to nibble on.
• C. Drink at least eight glasses of water each day.
• D. Make a list of reasons for quitting smoking.

Correct answer: C

Rationale: When teaching a client interested in smoking cessation, the nurse should advise finding an activity that keeps the hands busy, keeping healthy snacks on hand, making a list of reasons for quitting smoking, and not being upset if a relapse occurs. Drinking eight glasses of water each day is a healthy habit but is not directly related to smoking cessation strategies, making it the option that does not apply in this context.

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