Nursing Elites

1. 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.

2. A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?

• A. Provide respiratory support.
• B. Place the client in droplet isolation.
• C. Administer antihypertensive medications.
• D. Monitor ascites.

Correct answer: A

Rationale: In the late stage of inhalation anthrax, respiratory support is crucial due to the potential for respiratory failure. Providing oxygen therapy and maintaining airway patency are essential components of care to improve oxygenation and support respiratory function. Placing the client in droplet isolation is not necessary as inhalation anthrax is not transmitted from person to person through respiratory droplets. Administering antihypertensive medications is not indicated in the treatment of inhalation anthrax. Monitoring for ascites is not a priority in the late stage of inhalation anthrax.

3. A client with COPD is developing a plan of care. Which of the following interventions should the nurse include in the plan?

• A. Restrict the client's fluid intake to less than 2 L/day
• B. Provide the client with a low-protein diet
• C. Have the client use the early-morning hours for exercise and activity
• D. Instruct the client to use pursed-lip breathing

Correct answer: D

Rationale: In COPD, pursed-lip breathing helps improve breathing efficiency by maintaining positive pressure in the airways, preventing airway collapse, and promoting oxygenation. This technique assists in controlling respiratory rate, reducing dyspnea, and enhancing oxygen saturation levels. Restricting fluid intake is not typically a part of COPD management. Providing a low-protein diet is not a standard intervention for COPD. Early-morning hours are generally not recommended for exercise due to cooler temperatures and higher pollution levels, which can exacerbate COPD symptoms.

4. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

• A. Severe dyspnea
• B. Nausea
• C. Decreased level of consciousness
• D. Headache

Correct answer: B

Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.

5. A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?

• A. I will take my medication as prescribed.
• B. I will need to have regular follow-up chest x-rays.
• C. I will be able to return to work immediately.
• D. I will use tissues to cover my mouth when I cough.

Correct answer: C

Rationale: Clients with tuberculosis should not return to work until they are no longer contagious and have been cleared by their healthcare provider. This usually requires several weeks of treatment. The other statements are correct and indicate understanding.

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