Nursing Elites

1. A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

• A. Rest in a side-lying position after the tube is removed.
• B. Use the incentive spirometer every 4 hours after the tube is removed.
• C. Avoid speaking for extended periods.
• D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.

Correct answer: C

Rationale: It is essential to advise the client to avoid speaking for extended periods after the removal of the endotracheal tube to prevent strain on the vocal cords and allow the airway to recover. Speaking for prolonged periods can lead to irritation and potentially affect the healing process. The other options are also important post-extubation instructions, such as using the incentive spirometer to maintain lung function, positioning in a side-lying position for comfort, and frequent monitoring of vital signs to ensure the client's stability.

2. During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?

• A. Dullness
• B. Resonance
• C. Tympany
• D. Flatness

Correct answer: B

Rationale: In a client with chronic bronchitis, the nurse or healthcare provider would expect to hear resonant sounds upon percussion. Resonance is the normal percussion sound heard over healthy lung tissue. The other options such as dullness, tympany, and flatness are associated with different conditions or abnormalities, not typically expected in chronic bronchitis.

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. During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?

• A. Nausea
• B. Dysphagia
• C. Agitation
• D. Hypotension

Correct answer: C

Rationale: During an asthma attack, hypoxemia can lead to inadequate oxygen supply to the brain, causing symptoms like restlessness, confusion, and agitation. These manifestations result from the body's response to low oxygen levels, aiming to increase oxygenation. Nausea, dysphagia, and hypotension are not typical manifestations of hypoxemia during an asthma attack.

5. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

• A. Encourage the client and family to be active partners.
• B. Instruct the client to monitor hand hygiene in caregivers.
• C. Offer the family the opportunity to stay with the client.
• D. Advise the client to always wear their armband.

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

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