Nursing Elites

1. A healthcare provider is preparing to care for a client following chest tube placement. Which of the following items should NOT be available in the client's room?

• A. Oxygen
• B. Sterile water
• C. Enclosed hemostat clamps
• D. Indwelling urinary catheter

Correct answer: D

Rationale: Following chest tube placement, an indwelling urinary catheter is not typically needed or relevant to the care provided. Chest tube placement is primarily concerned with managing pleural effusion or pneumothorax, and urinary catheterization is not directly related to this procedure. Oxygen, sterile water, and enclosed hemostat clamps are commonly used items in the care of a client with a chest tube in place, to ensure proper oxygenation, maintain drainage system integrity, and manage any bleeding that may occur. Therefore, the indwelling urinary catheter should not be available in the client's room following chest tube placement.

2. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

3. What is the most appropriate nursing order for a patient who develops dyspnea and shortness of breath?

• A. Maintain the patient on strict bed rest at all times
• B. Maintain the patient in an orthopneic position as needed
• C. Administer high-flow oxygen immediately
• D. Encourage the patient to engage in vigorous physical activity

Correct answer: B

Rationale: Maintaining the patient in an orthopneic position as needed is the most appropriate nursing order for a patient experiencing dyspnea and shortness of breath. This position helps to optimize lung expansion, improve oxygenation, and alleviate breathing difficulties. It is a strategic intervention to enhance respiratory function in patients with respiratory distress. Choice A is incorrect because strict bed rest may not address the underlying respiratory issue effectively. Choice C is premature as administering high-flow oxygen should be based on a comprehensive assessment. Choice D is inappropriate as encouraging vigorous physical activity can exacerbate breathing problems in a patient experiencing dyspnea.

4. A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?

• A. Obtain the newborn's body temperature using a tympanic thermometer.
• B. FACES pain scale.
• C. Auscultate the newborn's apical pulse for 60 seconds.
• D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.

Correct answer: C

Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.

5. Which of the following techniques involves the sense of sight?

• A. Inspection
• B. Palpation
• C. Percussion
• D. Auscultation

Correct answer: A

Rationale: The correct answer is Inspection (Choice A). Inspection is a technique that involves observing the patient using the sense of sight. During inspection, a healthcare provider visually examines the patient for any abnormalities, changes, or specific signs that may help in diagnosing a condition. Palpation (Choice B) involves using the sense of touch to feel for abnormalities. Percussion (Choice C) involves tapping the body to produce sounds that can help identify the underlying structures. Auscultation (Choice D) involves listening to sounds produced by the body, typically using a stethoscope. Therefore, in this context, the technique that specifically involves the sense of sight is Inspection.

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