Nursing Elites

1. A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?

• A. Fremitus
• B. Hyperresonance
• C. Dullness on percussion
• D. Decreased tactile fremitus

Correct answer: C

Rationale: Pneumonia often leads to the consolidation of lung tissue, resulting in dullness on percussion. This occurs due to the presence of fluid or inflammatory material in the alveoli. Fremitus and decreased tactile fremitus are more indicative of conditions like pleural effusion or pneumothorax, where there is an increase in the density of the pleural space or air in the pleural cavity. Hyperresonance, on the other hand, is typically associated with conditions causing air trapping, such as emphysema, where there is increased air in the alveoli.

2. When performing tracheostomy care, which intervention should the nurse implement?

• A. Use aseptic technique.
• B. Clean the inner cannula with mild soap and water.
• C. Secure new tracheostomy ties before removing old ones.
• D. Apply suction when inserting the catheter.

Correct answer: C

Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.

3. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

4. A healthcare professional is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?

• A. Increased temperature
• B. Absent breath sounds
• C. Productive cough
• D. Incisional discomfort

Correct answer: B

Rationale: Absent breath sounds may indicate a pneumothorax, a serious complication post lung biopsy. This condition requires immediate attention to prevent respiratory distress.

5. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

• A. Withhold food and liquids until the client's gag reflex returns.
• B. Irrigate the client's throat every 4 hours.
• C. Have the client refrain from talking for 24 hours.
• D. Suction the client's oropharynx frequently.

Correct answer: A

Rationale: After a flexible bronchoscopy, it is crucial to withhold food and liquids until the client's gag reflex returns to prevent aspiration. Irrigating the client's throat every 4 hours, having the client refrain from talking for 24 hours, and frequent suctioning of the oropharynx are not indicated post-bronchoscopy and may even pose risks to the client's recovery.

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