Nursing Elites

1. A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?

• A. Average daily fluid intake
• B. Neck circumference
• C. Height & weight
• D. Occupation & hobbies

Correct answer: D

Rationale: Obtaining information about a client's occupation and hobbies is crucial when assessing respiratory status as many respiratory problems can result from chronic exposure to inhalation irritants related to these activities. Understanding the client's potential exposure can help the healthcare professional identify risk factors and provide appropriate interventions to promote respiratory health.

2. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

• A. Pain severity
• B. Wound drainage
• C. Tissue integrity
• D. Airway patency

Correct answer: D

Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.

3. What instruction should be included when teaching a client with asthma about using a metered-dose inhaler (MDI)?

• A. Shake the inhaler well before use.
• B. Inhale rapidly while administering the medication.
• C. Administer the medication while lying down.
• D. Hold the inhaler 2 inches away from the mouth while inhaling.

Correct answer: A

Rationale: Shaking the inhaler well before use ensures that the medication is properly mixed, allowing for an accurate dose with each administration. Inhaling slowly and deeply, not rapidly, helps the medication reach the lungs effectively. The medication should be administered while sitting or standing to facilitate proper lung expansion and airflow. Holding the inhaler 2 inches away from the mouth can lead to medication loss; it should be placed directly in the mouth or used with a spacer to optimize delivery to the airways.

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

• A. Accompanied by shortness of breath
• B. Feelings of fear or anxiety
• C. Lasts about 3-5 minutes
• D. Relieved by taking nitroglycerin

Correct answer: A

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.

5. A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?

• A. Chest tube eyelets not visible
• B. Continuous bubbling in the suction control chamber
• C. Presence of tidal fluctuation in the water seal chamber
• D. Development of subcutaneous emphysema

Correct answer: D

Rationale: The development of subcutaneous emphysema is a concerning finding that requires immediate intervention. Subcutaneous emphysema results from air leaking into the tissues, which can lead to respiratory compromise. It is important to address this issue promptly to prevent further complications. The other options are normal or expected findings in a chest tube drainage system. Chest tube eyelets not being visible may indicate dislodgement, continuous bubbling in the suction control chamber indicates proper functioning, and the presence of tidal fluctuation in the water seal chamber demonstrates appropriate drainage and lung re-expansion.

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