Nursing Elites

1. 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.

2. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?

• A. The client rates pain as 5/10 at the site of the procedure.
• B. A small amount of drainage is noted from the site.
• C. Pulse oximetry reads 93% on 2 liters of oxygen.
• D. The trachea is deviated toward the opposite side of the neck.

Correct answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

3. A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?

• A. Bradycardia
• B. Bradypnea
• C. Lethargy
• D. Intercostal retractions

Correct answer: D

Rationale: Postoperative atelectasis can lead to hypoxia, which causes respiratory distress. Intercostal retractions, where the muscles between the ribs pull inward during inspiration, are a common sign of respiratory distress in a client with atelectasis. Bradycardia (slow heart rate), Bradypnea (slow breathing rate), and lethargy are not typically associated with atelectasis and hypoxia.

4. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

• A. Increase the oxygen flow to 3 L/min.
• B. Assess the client's respiratory status.
• C. Call emergency services for the client.
• D. Have the client cough and expectorate secretions.

Correct answer: B

Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.

5. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

• A. Monitoring urine output
• B. Checking blood glucose levels
• C. Assessing for chest pain
• D. Monitoring electrolyte levels

Correct answer: C

Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.

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