Nursing Elites

1. A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

• A. Administer prescribed salmeterol (Serevent) inhaler.
• B. Assess the client for a tracheal deviation.
• C. Administer oxygen to maintain saturations above 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation suggests the client is using accessory muscles due to difficulty in moving air into the respiratory passages caused by airway narrowing. The presence of bilateral wheezing and decreased pulse oxygen saturation further support airway narrowing. In this situation, immediate intervention is necessary to improve oxygenation. Administering oxygen to maintain saturations above 94% is crucial to support oxygenation. While administering a rescue inhaler may be warranted, the priority in this scenario is ensuring adequate oxygenation to address the respiratory distress.

2. A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?

• A. Increase the wall suction.
• B. Strip the chest tube.
• C. Clamp the chest tube.
• D. Reposition the client.

Correct answer: D

Rationale: When a client with a chest tube connected to wall suction complains of chest burning, it may indicate that the tube is irritating or compressing nearby tissues. Repositioning the client can help relieve this irritation by ensuring the tube is not kinked or pulling on the tissues. Increasing suction, stripping the tube, or clamping it are not appropriate actions and could potentially worsen the situation or cause harm.

3. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

• A. Raise the affected extremity above the level of the heart.
• B. Immobilize the affected extremity with a splint
• C. Apply ice to the bite area
• D. Apply a tourniquet to the affected extremity.

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

4. A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?

• A. Decreased chest expansion
• B. Cyanosis
• C. Pursed-lip breathing
• D. Bradypnea

Correct answer: C

Rationale: Pursed-lip breathing is a common manifestation in clients with emphysema. It helps to increase the duration of exhalation and reduce air trapping, aiding in the management of the condition. Decreased chest expansion and bradypnea are not typically associated with emphysema. While cyanosis can occur in severe cases, pursed-lip breathing is a more specific and commonly observed sign of emphysema.

5. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

• A. Decreased anteroposterior chest diameter
• B. Increased breath sounds
• C. Prolonged expiratory phase
• D. Increased chest expansion

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

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