Nursing Elites

1. 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.

2. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

• A. Severe dyspnea
• B. Nausea
• C. Decreased level of consciousness
• D. Headache

Correct answer: B

Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.

3. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

• A. Oxygen saturation of 95%
• B. No fluctuations in the water seal chamber
• C. No reports of pleuritic chest pain
• D. Occasional bubbling in the water-seal chamber

Correct answer: B

Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.

4. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

• A. Pain severity
• B. Wound drainage
• C. Tissue integrity
• D. Airway patency

Correct answer: D

Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.

5. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?

• A. Production of pink sputum
• B. Tracheal deviation
• C. Drainage greater than 70 mL/hr
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.

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