Nursing Elites

1. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

• A. Kussmaul respirations
• B. Apneustic respirations
• C. Cheyne-Stokes respirations
• D. Stridor

Correct answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

2. A patient is receiving discharge instructions after experiencing a stroke. Which instruction is most important for preventing another stroke?

• A. Take prescribed antihypertensive medications regularly.
• B. Engage in physical therapy exercises.
• C. Follow a low-fat, low-cholesterol diet.
• D. Attend regular follow-up appointments with the healthcare provider.

Correct answer: A

Rationale: The correct answer is to take prescribed antihypertensive medications regularly. Hypertension is a major risk factor for stroke, and controlling blood pressure through medication is crucial in preventing recurrent strokes. While physical therapy, diet, and follow-up appointments are also important aspects of post-stroke care, managing hypertension with medication takes precedence due to its direct impact on stroke prevention.

3. A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

• A. Never strip the tubing to maintain patency.
• B. Secure tubing junctions with tape to prevent accidental disconnections.
• C. Set wall suction at the level recommended by the device manufacturer.
• D. Keep padded clamps at the bedside for use if the drainage system is interrupted.

Correct answer: D

Rationale: To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.

4. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?

• A. The client rates pain as 5/10 at the site of the procedure.
• B. A small amount of drainage is noted from the site.
• C. Pulse oximetry reads 93% on 2 liters of oxygen.
• D. The trachea is deviated toward the opposite side of the neck.

Correct answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

5. When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?

• A. A client who is scheduled for an abdominal x-ray and is awaiting transport
• B. A client who has a prescription for discharge
• C. A client who received oral pain medication 30 minutes ago
• D. A client who told an assistive personnel he is short of breath

Correct answer: D

Rationale: When a client expresses being short of breath, it may indicate a serious condition requiring immediate attention to ensure adequate oxygenation. This client should be seen first to assess the severity of the situation and initiate appropriate interventions. The other options, such as awaiting transport for an x-ray, having a prescription for discharge, or receiving oral pain medication 30 minutes ago, do not present immediate life-threatening concerns compared to a client experiencing shortness of breath.

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