Nursing Elites

1. During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?

• A. Loud wheezing
• B. Increased respiratory rate
• C. Decreased breath sounds
• D. Productive cough

Correct answer: C

Rationale: In a client experiencing an acute asthma attack, decreased breath sounds suggest severe airway obstruction or respiratory fatigue, indicating a worsening condition. Loud wheezing, increased respiratory rate, and a productive cough are common manifestations during an asthma attack as the airways constrict, leading to turbulent airflow causing wheezing, increased effort to breathe resulting in a higher respiratory rate, and mucus production causing a productive cough. However, decreased breath sounds signify a critical situation requiring immediate intervention.

2. How does the pain of a myocardial infarction (MI) differ from stable angina? (SATA)

• A. Accompanied by shortness of breath
• B. Feelings of fear or anxiety
• C. Lasts longer than 15 minutes
• D. Relieved by taking nitroglycerin

Correct answer: A, C

Rationale: The pain of an MI is often accompanied by shortness of breath and feelings of fear or anxiety. It typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Unlike stable angina, the pain of an MI occurs without a known cause such as exertion.

3. While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?

• A. Notify the operating room of a potential emergency case.
• B. No action is required at this time; this pulsation can be a normal finding in some clients.
• C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
• D. Stay with the client and ask someone else to contact the provider immediately.

Correct answer: D

Rationale: The pulsation of the tracheostomy tube with the heartbeat may indicate a tracheoinnominate artery fistula, which can lead to life-threatening hemorrhage if the artery is breached. In this scenario, as there is no active bleeding yet, the nurse should remain with the client and have another person notify the provider immediately. If the client starts to hemorrhage, the nurse should remove the tracheostomy tube and apply pressure at the bleeding site, preparing the client for urgent surgical intervention.

4. While dining at a restaurant, a person begins to choke. Which of the following actions should the nurse take?

• A. Instruct the person to call 911.
• B. Ask the person if he/she can speak.
• C. Use the jaw-thrust maneuver.
• D. Perform abdominal thrusts.

Correct answer: Ask the person if he/she can speak.

Rationale: When encountering a choking individual, the nurse should first assess the person's ability to speak. If the person can speak, it indicates that their airway is partially obstructed, allowing some air to pass. In this case, encouraging the person to continue coughing and monitoring them closely may be appropriate. If the person cannot speak, it may suggest a complete airway obstruction and immediate intervention is required. Instructing the person to call 911 (Choice A) may be necessary if the situation worsens. Using the jaw-thrust maneuver (Choice C) is not appropriate for a choking victim. Performing abdominal thrusts (Choice D) is typically recommended for conscious choking victims, not chest compressions.

5. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

• A. Prevent aspiration.
• B. Ensure adequate nutrition.
• C. Promote oral hygiene.
• D. Relieve the client's pain.

Correct answer: Prevent aspiration.

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

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