Nursing Elites

1. A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

• A. Patency of the intravenous line
• B. Level of pain
• C. Integrity of the dressing
• D. Need for suctioning

Correct answer: D

Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.

2. A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?

• A. I can have clear liquids up to 2 hours before the procedure.
• B. I need to take a laxative the night before the procedure.
• C. I will be sedated during the procedure.
• D. I should avoid eating solid foods for 24 hours before the procedure.

Correct answer: D

Rationale: The correct answer is D because clients are typically instructed to avoid solid foods for 12-24 hours before a colonoscopy, not a full 24 hours. This statement indicates a need for further teaching to ensure the client follows the correct dietary instructions for the procedure.

3. A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)

• A. Administer prescribed albuterol (Ventolin) inhaler.
• B. Assess the client for tracheal deviation.
• C. Administer oxygen to maintain saturations greater than 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation indicates the use of accessory muscles and difficulty in moving air due to airway narrowing, supported by bilateral wheezing and decreased pulse oxygen saturation. This client needs immediate intervention as their asthma is not responding to the medication. Administering oxygen to maintain saturations above 94% is crucial to ensure adequate oxygenation. While administering a rescue inhaler could also be necessary, oxygen therapy takes priority in this situation.

4. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?

• A. Constant bubbling in the suction-control chamber
• B. Continuous bubbling in the water-seal chamber
• C. Bloody drainage in the collection chamber
• D. Fluid-level fluctuations in the water-seal chamber

Correct answer: B

Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.

5. A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

• A. Continuous bubbling in the water-seal chamber
• B. Occasional bubbling in the water-seal chamber
• C. Constant bubbling in the suction-control chamber
• D. Fluctuations in the fluid level in the water-seal chamber

Correct answer: A

Rationale: Continuous bubbling in the water-seal chamber indicates air is leaking into the pleural space, which is a complication. The water-seal chamber should have intermittent bubbling during normal functioning. Occasional bubbling in the water-seal chamber is normal and shows the system is working as intended. Constant bubbling in the suction-control chamber suggests an issue with the suction control. Fluctuations in the fluid level in the water-seal chamber are an expected finding.

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