Nursing Elites

1. A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?

• A. Continue suctioning to remove the blood
• B. Check the degree of suction being applied
• C. Encourage the client to cough out the bloody secretions
• D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth

Correct answer: B

Rationale: The correct answer is to check the degree of suction being applied (Choice B). When bloody secretions are encountered during nasopharyngeal suctioning, it is crucial to assess the situation promptly. Checking the degree of suction being applied is the first step as excessive suction pressure may be causing trauma and bleeding. Adjusting the suction pressure may be necessary to prevent further harm. Continuing suctioning to remove the blood (Choice A) or performing vigorous suctioning through the mouth (Choice D) can lead to increased trauma and worsen bleeding. Encouraging the client to cough out the bloody secretions (Choice C) is not appropriate since the client undergoing suctioning is typically unable to expectorate secretions. Therefore, the priority is to check and adjust the suction settings to ensure safe and effective suctioning.

2. A client has been scheduled for magnetic resonance imaging (MRI). For which of the following conditions, a contraindication to MRI, does the nurse check the client’s medical history?

• A. Pancreatitis
• B. Pacemaker insertion
• C. Type 1 diabetes mellitus
• D. Chronic airway limitation

Correct answer: B

Rationale: The correct answer is B: Pacemaker insertion. Patients with metal devices or implants are contraindicated for MRI. These include pacemakers, orthopedic hardware, artificial heart valves, aneurysm clips, and intrauterine devices. These metal objects can be affected by the strong magnetic field of the MRI, leading to serious risks for the patient. Pancreatitis (choice A), Type 1 diabetes mellitus (choice C), and chronic airway limitation (choice D) are not contraindications to MRI based on the presence of metal objects. Therefore, the nurse should be particularly concerned about pacemaker insertion when reviewing the client's medical history prior to an MRI.

3. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked, and his eyeballs are sunken into his head. What nursing intervention is indicated?

• A. Help the client determine ways to increase his fluid intake.
• B. Obtain an appointment for the client to see a pulmonologist.
• C. Schedule an appointment with a nutritionist to assess the client's diet.
• D. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen.

Correct answer: A

Rationale: The correct nursing intervention in this scenario is to assist the client in finding ways to increase his fluid intake. Clients with COPD, including emphysema, should aim to consume at least three liters of fluids per day to help keep their mucus thin. As the disease progresses, these clients may decrease fluid intake due to various reasons. Suggesting creative methods, such as having disposable fruit juices readily available, can help the client meet this goal. Option B is incorrect as seeing an ear, nose, and throat specialist is not directly related to the client's symptoms. Option C is not the priority in this case, as the main concern is addressing the client's dehydration. Option D does not address the immediate need for managing the client's dehydration and is not the most appropriate intervention at this time.

4. In a patient with anemia, which of the following is the primary symptom to assess?

• A. Fever.
• B. Chest pain.
• C. Shortness of breath.
• D. Muscle cramps.

Correct answer: C

Rationale: The correct answer is C: Shortness of breath. In a patient with anemia, the primary symptom to assess is shortness of breath. Anemia leads to a reduced oxygen-carrying capacity of the blood, resulting in tissues not receiving adequate oxygen. This can manifest as shortness of breath, especially during physical exertion. Fever (Choice A), chest pain (Choice B), and muscle cramps (Choice D) are not typically primary symptoms of anemia. Fever may suggest an infection, chest pain can be indicative of cardiac issues, and muscle cramps may be related to electrolyte imbalances or neuromuscular disorders.

5. A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min via nasal cannula. What should the nurse do next?

• A. Call for the physician.
• B. Start an IV infusion.
• C. Obtain a portable chest radiograph.
• D. Draw blood for laboratory studies.

Correct answer: B

Rationale: In a client presenting with possible myocardial infarction who is receiving oxygen therapy and cardiac monitoring, the next priority action is to establish IV access by starting an IV infusion. This allows for prompt administration of medications and fluids as needed in the management of acute coronary syndromes. Calling the physician (Choice A) may be necessary but is not the immediate next step. Obtaining a portable chest radiograph (Choice C) may help in further assessment but is not as crucial as establishing IV access. Drawing blood for laboratory studies (Choice D) is important for diagnostic purposes but is not as urgent compared to starting an IV infusion in the setting of a potential myocardial infarction.

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