Nursing Elites

1. During auscultation of the anterior chest wall of a client newly admitted to a medical-surgical unit, what type of breath sounds should a nurse expect to hear?

• A. Normal breath sounds
• B. Adventitious breath sounds
• C. Absent breath sounds
• D. Diminished breath sounds

Correct answer: A

Rationale: During auscultation of the chest, normal breath sounds are the expected findings in a client who is newly admitted without respiratory complaints. Normal breath sounds indicate proper airflow through the airways without any abnormalities. Adventitious breath sounds (Choice B) refer to abnormal lung sounds such as crackles or wheezes, which are indicative of underlying respiratory issues. Absent breath sounds (Choice C) suggest a lack of airflow to a particular lung area, which could be due to conditions like pneumothorax. Diminished breath sounds (Choice D) indicate reduced airflow or consolidation in a specific lung region, often seen in conditions like pleural effusion or pneumonia. Therefore, in a newly admitted client without respiratory complaints, the nurse should expect to hear normal breath sounds during auscultation.

2. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?

• A. Place a pad under the client’s head
• B. Hold the client’s limbs tightly to prevent injury
• C. Lift the client into bed with the help of other staff members
• D. Insert a bite block into the client’s mouth

Correct answer: A

Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.

3. A healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, a serious condition that requires immediate attention. It can be a sign of an air leak in the lung or surrounding tissues. Constant bubbling in the suction control chamber is expected in a functioning chest tube system as it indicates proper suction. Intermittent bubbling in the water seal chamber is also normal, showing that the system is functioning correctly, allowing air to escape but not re-enter. Drainage of 50 ml per hour is within the expected range for chest tube output and does not require immediate intervention unless there are other concerning signs such as rapid increase or a sudden change in color or consistency.

4. The patient is receiving chemotherapy for breast cancer. Which of the following laboratory values would be most important to monitor?

• A. White blood cell count
• B. Hemoglobin level
• C. Serum creatinine
• D. Blood glucose level

Correct answer: A

Rationale: Monitoring the white blood cell count is crucial when a patient is undergoing chemotherapy for breast cancer. Chemotherapy can lead to neutropenia, a condition of low white blood cell count, which significantly increases the risk of infections. Monitoring white blood cell count helps healthcare providers intervene promptly to prevent severe infections. Hemoglobin level, while important in assessing oxygen-carrying capacity, is not the priority in this scenario. Serum creatinine and blood glucose levels are not directly impacted by chemotherapy for breast cancer.

5. When developing a plan of care for a client with dementia, what should the LPN/LVN remember about confusion in the elderly?

• A. It is not a normal part of aging.
• B. It often follows relocation to new surroundings.
• C. It is primarily due to changes in the brain associated with the disease.
• D. It cannot be prevented or cured by adequate sleep alone.

Correct answer: B

Rationale: When caring for a client with dementia, it is crucial to understand that confusion often arises after relocating to new surroundings. This change can disrupt familiar routines and trigger increased disorientation and confusion. Choice A is correct because confusion in the elderly is not a normal part of aging. Choice C is incorrect because confusion in dementia is primarily due to changes in the brain associated with the disease, not just irreversible brain pathology. Choice D is incorrect because while adequate sleep is important for overall health, it alone cannot prevent or cure confusion associated with dementia.

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