Nursing Elites

1. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

• A. Since many of your family members are carriers, your children will also be carriers of the gene.
• B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
• C. Since you have a family history of cystic fibrosis, I would encourage you & your partner to be tested.
• D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.

Correct answer: C

Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.

2. After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?

• A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
• B. Client's HR is 55 beats/min. Nurse withholds pain medication.
• C. Client has reduced breath sounds. Nurse calls the physician immediately.
• D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.

Correct answer: C

Rationale: After an open lung biopsy, a potential complication is pneumothorax, often indicated by reduced or absent breath sounds. The nurse should promptly notify the physician to address this serious issue and ensure timely intervention.

3. A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?

• A. Arterial blood gases
• B. Urinary output
• C. Chest tube drainage
• D. Pain level

Correct answer: A

Rationale: Arterial blood gases are crucial to assess postoperatively in a client who has undergone thoracotomy and lobectomy to monitor oxygenation and ventilation status. Changes in arterial blood gases can indicate respiratory complications or inadequate gas exchange, which are critical issues that need prompt intervention to prevent further complications. While urinary output, chest tube drainage, and pain level are important assessments, monitoring arterial blood gases takes precedence in this specific postoperative scenario to ensure optimal respiratory function and overall patient well-being.

4. 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.

5. Prior to a cardiac catheterization, what is the most important action for the nurse to take?

• A. Ensure that the client has been NPO for 6 hours before the procedure.
• B. Administer pre-procedure medications as ordered.
• C. Verify that informed consent has been obtained.
• D. Assess the client for any allergies, especially to iodine or shellfish.

Correct answer: D

Rationale: Assessing the client for allergies, particularly to iodine or shellfish, is crucial before a cardiac catheterization because the contrast dye used during the procedure can lead to allergic reactions. Identifying any allergies beforehand allows the healthcare team to take necessary precautions to prevent potential adverse reactions and ensure the client's safety.

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