Nursing Elites

1. A healthcare provider is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the provider place at the client's bedside?

• A. Bag valve mask device
• B. Defibrillator machine
• C. Chest tube equipment
• D. Central venous catheter tray

Correct answer: A

Rationale: When a client receives a competitive neuromuscular blocking agent, it can lead to respiratory muscle paralysis. Placing a bag valve mask device at the client's bedside is crucial for providing immediate respiratory support in case of respiratory depression or failure. This device allows manual ventilation by squeezing the bag to deliver breaths to the client. The other options, such as a defibrillator machine, chest tube equipment, and central venous catheter tray, are not directly related to managing respiratory complications associated with neuromuscular blockade.

2. A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?

• A. Take the medication with food to avoid stomach upset.
• B. Avoid exposure to sunlight while taking this medication.
• C. Report any numbness or tingling in extremities.
• D. Have liver function tests done regularly.

Correct answer: D

Rationale: Regular monitoring of liver function tests is crucial for clients taking isoniazid (INH) due to the potential risk of hepatotoxicity. Isoniazid can cause liver damage, and early detection through routine liver function tests can help prevent severe complications.

3. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?

• A. Constant bubbling in the suction-control chamber
• B. Continuous bubbling in the water-seal chamber
• C. Bloody drainage in the collection chamber
• D. Fluid-level fluctuations in the water-seal chamber

Correct answer: B

Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.

4. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

• A. The client demonstrates a good understanding of stoma care.
• B. The client has joined a book club that meets at the library.
• C. Family members take turns assisting with stoma care.
• D. Skin around the stoma is intact without signs of infection.

Correct answer: B

Rationale: The client joining a book club that meets outside the home and requires him or her to go out in public is the best indicator that goals for Impaired Self-Esteem are being met. This social activity indicates an improvement in self-confidence and willingness to engage with others, which are essential aspects of self-esteem. The other choices, while positive, do not directly address self-esteem concerns related to social interaction and confidence.

5. A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

• A. Provide high-flow oxygen.
• B. Check the client for a positive Chvostek's sign.
• C. Administer an IV vasopressor medication.
• D. Monitor the client for headache.

Correct answer: A

Rationale: In this situation, the priority action is to provide high-flow oxygen to the client. Sudden onset dyspnea and severe chest pain can be indicative of a pulmonary embolism, which is a life-threatening emergency. Oxygen therapy helps improve oxygenation and stabilizes the client's condition. Checking for Chvostek's sign, administering IV vasopressors, or monitoring for a headache are not the immediate priorities in this critical situation.

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