Nursing Elites

1. A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?

• A. Provide respiratory support.
• B. Place the client in droplet isolation.
• C. Administer antihypertensive medications.
• D. Monitor ascites.

Correct answer: A

Rationale: In the late stage of inhalation anthrax, respiratory support is crucial due to the potential for respiratory failure. Providing oxygen therapy and maintaining airway patency are essential components of care to improve oxygenation and support respiratory function. Placing the client in droplet isolation is not necessary as inhalation anthrax is not transmitted from person to person through respiratory droplets. Administering antihypertensive medications is not indicated in the treatment of inhalation anthrax. Monitoring for ascites is not a priority in the late stage of inhalation anthrax.

2. A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?

• A. Holding the device securely when changing ties
• B. Suctioning the client first if secretions are present
• C. Tying a square knot at the back of the neck
• D. Using half-strength peroxide for cleansing

Correct answer: C

Rationale: When providing tracheostomy care, it is important to ensure the client's safety and prevent pressure ulcers. When securing ties that require knotting, the knot should be placed at the side of the client's neck, not at the back. Tying a square knot at the back of the neck could lead to discomfort, pressure ulcers, or accidental tightening. Holding the device securely, suctioning the client as needed, and using appropriate cleansing solutions are all essential components of tracheostomy care.

3. A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?

• A. Clamp the chest tube prior to transferring the client to a wheelchair.
• B. Disconnect the chest tube from the drainage system during transport.
• C. Keep the drainage system below the level of the client's chest at all times.
• D. Empty the collection chamber prior to transport.

Correct answer: C

Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.

4. 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.

5. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?

• A. Allow family members to remain at the bedside.
• B. Ask the family if the client would like a fan in the room.
• C. Keep the television tuned to the client's favorite channel.
• D. Speak loudly to the client in case of hearing problems.

Correct answer: A

Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.

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