Nursing Elites

1. A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?

• A. Blood glucose level
• B. Serum sodium level
• C. Serum calcium level
• D. Blood urea nitrogen (BUN)

Correct answer: A

Rationale: In a client presenting with a new onset of confusion, checking the blood glucose level first is crucial as hypoglycemia can cause confusion and is easily correctable. Addressing hypoglycemia promptly is essential to prevent further complications.

2. A client with newly diagnosed osteoporosis is being taught about lifestyle modifications. Which instruction should be included?

• A. Increase intake of caffeinated beverages.
• B. Engage in weight-bearing exercises regularly.
• C. Avoid exposure to sunlight.
• D. Take calcium supplements with iron.

Correct answer: B

Rationale: Engaging in weight-bearing exercises is crucial for individuals with osteoporosis as it helps strengthen bones and reduce the risk of fractures. Weight-bearing exercises include activities like walking, jogging, dancing, and strength training. These exercises help improve bone density and overall bone health, making them an essential component of lifestyle modifications for individuals with osteoporosis.

3. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?

• A. Movement of the trachea toward the unaffected side
• B. Bubbling of the water in the water seal chamber with exhalation
• C. Crepitus in the area above and surrounding the insertion site
• D. Eyelets not visible

Correct answer: A

Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.

4. A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?

• A. Administer albuterol treatment.
• B. Notify Rapid Response Team.
• C. Assess the client's peripheral pulses.
• D. Obtain blood and sputum cultures.

Correct answer: B

Rationale: Cyanosis unresponsive to oxygen therapy suggests methemoglobinemia, an adverse effect of benzocaine spray. Methemoglobinemia can lead to death if not managed promptly. The nurse should notify the Rapid Response Team to provide immediate advanced care. Administering albuterol would not address the underlying cause of cyanosis. Assessing peripheral pulses and obtaining cultures are not the priority as they do not directly address the urgent need to manage methemoglobinemia.

5. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?

• A. Production of pink sputum
• B. Tracheal deviation
• C. Drainage greater than 70 mL/hr
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.

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