Nursing Elites

1. Prior to performing percussion, vibration, and postural drainage on an adolescent client with pneumonia, which of the following nursing actions should the nurse complete first?

• A. Auscultate lung fields
• B. Assess pulse and respirations
• C. Assess characteristics of the sputum
• D. Instruct the client to slowly exhale with pursed lips

Correct answer: A

Rationale: Before initiating percussion, vibration, and postural drainage, the nurse should first auscultate the lung fields to assess the baseline lung sounds and identify areas of congestion or abnormality. This initial assessment helps the nurse to tailor the percussion and drainage techniques effectively. Assessing pulse and respirations, sputum characteristics, and providing instructions to the client for exhalation are important steps in the procedure but should follow the initial auscultation to ensure a comprehensive and individualized care approach.

2. A healthcare professional is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the healthcare professional anticipate administering?

• A. Furosemide
• B. Dexamethasone
• C. Heparin
• D. Atropine

Correct answer: C

Rationale: In the scenario of a pulmonary embolism, the priority medication to administer is Heparin. Heparin is an anticoagulant that helps prevent the formation of new blood clots and the growth of existing ones, which is crucial in managing pulmonary embolism. Furosemide is a diuretic used to treat fluid retention, Dexamethasone is a corticosteroid used for inflammation, and Atropine is an anticholinergic medication used for various purposes such as treating bradycardia.

3. How does the pain of a myocardial infarction (MI) differ from stable angina?

• A. Accompanied by shortness of breath
• B. Feelings of fear or anxiety
• C. Lasts about 3-5 minutes
• D. Relieved by taking nitroglycerin

Correct answer: A

Rationale: The pain of an MI is often accompanied by shortness of breath and feelings of fear or anxiety. It typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Unlike stable angina, the pain of an MI occurs without a known cause such as exertion.

4. 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.

5. During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?

• A. Dysphagia
• B. Hoarseness
• C. Dyspnea
• D. Weight loss

Correct answer: B

Rationale: In clients with laryngeal cancer, hoarseness is often one of the earliest manifestations due to vocal cord involvement. The irritation and inflammation caused by the tumor affect the vocal cords, leading to changes in voice quality. Dysphagia (choice A) typically occurs later as the tumor grows and interferes with swallowing. Dyspnea (choice C) and weight loss (choice D) may occur as the cancer progresses, but hoarseness is usually among the first signs to manifest in laryngeal cancer.

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