Nursing Elites

1. A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?

• A. I will breathe in quickly through my mouth and out through my nose.
• B. I will breathe in slowly through my nose and out through pursed lips.
• C. I will hold my breath for 10 seconds before exhaling.
• D. I will breathe in and out through pursed lips.

Correct answer: B

Rationale: The correct technique for pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips. This technique helps improve expiration and reduce air trapping. Breathing in quickly, holding the breath, or breathing in and out through pursed lips does not align with the correct method of pursed-lip breathing.

2. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?

• A. The client rates pain as 5/10 at the site of the procedure.
• B. A small amount of drainage is noted from the site.
• C. Pulse oximetry reads 93% on 2 liters of oxygen.
• D. The trachea is deviated toward the opposite side of the neck.

Correct answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

3. A nursing student asks what essential hypertension is. What response by the registered nurse is best?

• A. It means it is caused by another disease.
• B. It means it is essential that it be treated.
• C. It is hypertension with no specific cause.
• D. It refers to severe and life-threatening hypertension.

Correct answer: C

Rationale: Essential hypertension, also known as primary or idiopathic hypertension, is the most common type of hypertension. It has no specific underlying cause such as an associated disease process. In contrast, hypertension that is due to another disease is referred to as secondary hypertension. Malignant hypertension is a severe and life-threatening form of hypertension characterized by rapidly progressive blood pressure elevation and potential end-organ damage.

4. A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?

• A. Bowel sounds
• B. Surgical dressing
• C. Temperature
• D. Oxygen saturation

Correct answer: D

Rationale: The priority assessment for a client being admitted to the surgical unit following a cholecystectomy is oxygen saturation. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and ventilation, especially after surgery. Hypoxia can have serious consequences and needs to be promptly addressed. While assessing bowel sounds, surgical dressing, and temperature are important, oxygen saturation takes precedence in this situation.

5. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

• A. Administer prescribed anxiolytic medication.
• B. Ensure informed consent is on the chart.
• C. Reinforce any teaching done previously.
• D. Start the preoperative antibiotic infusion.

Correct answer: B

Rationale: The priority action for the nurse is to ensure that informed consent is on the chart. Before any surgical procedure, it is essential to have the client's informed consent documented. While administering anxiolytics, starting antibiotic infusion, and reinforcing teaching may also be necessary, obtaining informed consent takes precedence to ensure the client's understanding and agreement to proceed with the tracheostomy.

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