Nursing Elites

1. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?

• A. The client is anxious about the procedure.
• B. The client has not eaten for 8 hours.
• C. The client has a reported allergy to shellfish.
• D. The client has a platelet count of 100,000/mm³.

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.

2. A nurse is preparing to administer a blood transfusion. What is the first action?

• A. Administer the blood through an IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Ensure the client eats before starting the transfusion

Correct answer: B

Rationale: The correct first action when preparing to administer a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to prevent transfusion reactions and complications. Option A is incorrect because blood transfusions should not be administered through an IV push due to the risk of rapid infusion and adverse reactions. Option C is incorrect because blood should be transfused at room temperature, not body temperature. Option D is incorrect because it is not necessary for the client to eat before a blood transfusion.

3. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

• A. The client's urine test is positive for glucose and acetone
• B. The client has 1+ pedal edema in both feet at the end of the day
• C. The client complains of an increase in vaginal discharge
• D. The client says she feels pressure against her diaphragm when the baby moves

Correct answer: A

Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.

4. A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?

• A. Ensure the chest tube is clamped periodically
• B. Check for air leaks and ensure proper chest tube function
• C. Encourage deep breathing and coughing every 2 hours
• D. Ensure the client is positioned in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.

5. What is the nurse's responsibility when managing a physically assaultive client?

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control
• D. Clear the area of other clients

Correct answer: C

Rationale: The correct answer is C: Restore the client's self-control. When managing a physically assaultive client, the nurse's responsibility is to help the client regain control over their actions and emotions. This is crucial in preventing harm to themselves and others. Restricting the client to the room (Choice A) may escalate the situation and is not a therapeutic approach. Placing the client under one-to-one supervision (Choice B) is important for safety but does not address the root cause of the behavior. Clearing the area of other clients (Choice D) is necessary for safety but does not directly address the client's self-control. Therefore, the priority in managing an assaultive client is to focus on restoring their self-control.

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