Nursing Elites

1. A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?

• A. Continue to monitor the client.
• B. Immediately notify the healthcare provider.
• C. Reposition the client to the left side.
• D. Clamp the chest tube near the water seal.

Correct answer: A

Rationale: In a client with a three-chamber closed chest tube system, a rise in the water seal chamber with client inspiration is an expected finding. The nurse should continue to monitor the client as this indicates that the system is functioning correctly. There is no need to notify the healthcare provider, reposition the client, or clamp the chest tube as these actions are not indicated in response to a rise in the water seal chamber.

2. A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?

• A. Serosanguineous drainage from the puncture site
• B. Discomfort at the puncture site
• C. Increased heart rate
• D. Decreased temperature

Correct answer: C

Rationale: Following a thoracentesis, it is crucial for healthcare professionals to monitor for potential complications. Increased heart rate can indicate hypovolemia or other serious issues, such as bleeding or pneumothorax, and requires immediate attention to prevent further complications. Serosanguineous drainage from the puncture site is a common expected finding post-procedure. Discomfort at the puncture site is also common and can be managed with appropriate interventions. Decreased temperature is not typically associated with complications following a thoracentesis. Therefore, the correct answer is increased heart rate as it signifies a potential serious complication that needs prompt medical evaluation.

3. During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?

• A. Lateral segment of the left lower lobe
• B. Lateral segment of the right lower lobe
• C. Posterior segment of the right middle lobe
• D. Posterior segment of the right lower lobe

Correct answer: B

Rationale: When a client is positioned on the left side in Trendelenburg position for pulmonary hygiene, secretions are expected to be mobilized from the lateral segment of the right lower lobe. This positioning helps facilitate drainage and clearance of secretions from this specific area of the lung, aiding in overall pulmonary hygiene and improving ventilation.

4. 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.

5. A client has an oxygen saturation of 88% on room air. Which action should the nurse take first?

• A. Initiate oxygen therapy at 2 liters per minute via nasal cannula.
• B. Place the client in a high-Fowler's position.
• C. Notify the healthcare provider.
• D. Document the finding in the client's medical record.

Correct answer: A

Rationale: The priority action for a client with an oxygen saturation of 88% on room air is to initiate oxygen therapy to improve oxygen saturation levels. Oxygen therapy is crucial to address hypoxemia promptly. Placing the client in a high-Fowler's position can also aid in oxygenation, but administering oxygen takes precedence. While notifying the healthcare provider is important, it is a secondary action after ensuring the client's immediate need for oxygen is met. Documenting the finding in the client's medical record is necessary for continuity of care but is not the primary intervention when addressing hypoxemia.

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