Nursing Elites

1. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

• A. Oxygen saturation of 95%
• B. No fluctuations in the water seal chamber
• C. No reports of pleuritic chest pain
• D. Occasional bubbling in the water-seal chamber

Correct answer: B

Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.

2. During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?

• A. Loud wheezing
• B. Increased respiratory rate
• C. Decreased breath sounds
• D. Productive cough

Correct answer: C

Rationale: In a client experiencing an acute asthma attack, decreased breath sounds suggest severe airway obstruction or respiratory fatigue, indicating a worsening condition. Loud wheezing, increased respiratory rate, and a productive cough are common manifestations during an asthma attack as the airways constrict, leading to turbulent airflow causing wheezing, increased effort to breathe resulting in a higher respiratory rate, and mucus production causing a productive cough. However, decreased breath sounds signify a critical situation requiring immediate intervention.

3. While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?

• A. Elevate the head of the bed to at least 30°.
• B. Verify the prescribed ventilator settings daily.
• C. Administer pantoprazole as prescribed.
• D. Reposition the endotracheal tube to the opposite side of the mouth daily.

Correct answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice and can increase the risk of complications, such as accidental extubation or damage to the airway. The endotracheal tube should remain in the initial correct position to ensure proper ventilation and prevent harm to the client. Elevating the head of the bed, verifying ventilator settings, and administering pantoprazole as prescribed are all appropriate interventions to prevent complications in a client receiving positive-pressure mechanical ventilation.

4. A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?

• A. Widened QRS complexes
• B. Hyperactive deep tendon reflexes
• C. Bounding peripheral pulses
• D. Warm, flushed skin

Correct answer: A

Rationale: Respiratory acidosis is a condition characterized by increased carbon dioxide levels in the blood, resulting in acidosis. One of the potential consequences of respiratory acidosis is the development of electrolyte imbalances, particularly hyperkalemia. Hyperkalemia can lead to cardiac conduction abnormalities, manifested as widened QRS complexes on an electrocardiogram (ECG). Therefore, in a client with respiratory acidosis, the healthcare professional should expect to find widened QRS complexes as a result of the associated hyperkalemia.

5. 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.

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