Nursing Elites

1. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

• A. Evaluate chest expansion.
• B. Check pupillary response to light.
• C. Assess the capillary refill.
• D. Check the client's response to questions about place and time.

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

2. While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

• A. Atelectasis
• B. Flail chest
• C. Hemothorax
• D. Pneumothorax

Correct answer: B

Rationale: Flail chest is characterized by paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration. This occurs due to multiple rib fractures causing a segment of the chest wall to move independently from the rest of the thorax. Atelectasis refers to collapsed lung tissue, hemothorax is blood in the pleural space, and pneumothorax is air in the pleural space. In this scenario, the client's presentation aligns with the characteristic findings of flail chest.

3. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?

• A. All staff nurses are required to participate in quality improvement projects.
• B. Even as a new nurse, you can implement activities designed to improve care.
• C. It's easy to identify which indicators should be used to measure quality improvement.
• D. You should ask to be assigned to the research and quality committee.

Correct answer: B

Rationale: The best response is to encourage the newly graduated nurse to actively participate in quality improvement initiatives. Being new does not preclude one from contributing to improving care processes and outcomes. By engaging in small activities focused on quality improvement, the new nurse can start making a positive impact and learn valuable skills early in their career.

4. A healthcare provider collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the healthcare provider include in communications with the respiratory therapist prior to the tests? (Select ONE that does not apply)

• A. I ensured the client did not use bronchodilator medication within the specified timeframe.
• B. The client is prepared to undergo the examination in radiology.
• C. Physical therapy has approved the client for treadmill exercise.
• D. I instructed the client not to smoke for the required duration before the test.

Correct answer: C

Rationale: For accurate pulmonary function tests (PFTs), it is essential to communicate that the client did not use bronchodilators within the specified timeframe, did not smoke for the required duration before the test, and can comply with different breathing maneuvers. The use of a treadmill is not part of the PFT procedure and is unrelated to the testing process. Therefore, communicating about the client's ability to run on a treadmill is not relevant to the pulmonary function tests being conducted by the respiratory therapist.

5. While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?

• A. Notify the operating room of a potential emergency case.
• B. No action is required at this time; this pulsation can be a normal finding in some clients.
• C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
• D. Stay with the client and ask someone else to contact the provider immediately.

Correct answer: D

Rationale: The pulsation of the tracheostomy tube with the heartbeat may indicate a tracheoinnominate artery fistula, which can lead to life-threatening hemorrhage if the artery is breached. In this scenario, as there is no active bleeding yet, the nurse should remain with the client and have another person notify the provider immediately. If the client starts to hemorrhage, the nurse should remove the tracheostomy tube and apply pressure at the bleeding site, preparing the client for urgent surgical intervention.

Similar Questions