Nursing Elites

1. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: Subcutaneous emphysema is the assessment finding that requires immediate intervention in a client with a chest tube following a pneumothorax. Subcutaneous emphysema can indicate a pneumothorax recurrence or air leak, which can compromise respiratory function and lead to serious complications. Oxygen saturation of 94% may be concerning but does not require immediate intervention as it is still within an acceptable range. Crepitus around the insertion site is common after chest tube placement and may not always indicate a problem. A blood pressure of 110/70 mmHg is within normal limits and does not require immediate intervention in this context.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding is most concerning to the nurse?

• A. Barrel-shaped chest
• B. Use of accessory muscles
• C. Oxygen saturation of 85%
• D. Respiratory rate of 28 breaths per minute

Correct answer: C

Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and indicates hypoxemia, requiring immediate intervention. In COPD, the body's ability to oxygenate adequately is already compromised, so a saturation of 85% is particularly concerning. A barrel-shaped chest and use of accessory muscles are common findings in COPD due to chronic air trapping and increased work of breathing. While a respiratory rate of 28 breaths per minute is elevated, a low oxygen saturation is a more critical finding that necessitates prompt attention.

3. Which instruction is most important for a client who receives a new plan of care to treat osteoporosis?

• A. Start a weight-bearing exercise plan.
• B. Increase consumption of foods rich in calcium.
• C. Arrange a bone density test every year.
• D. Stay upright after taking the medication.

Correct answer: D

Rationale: The correct answer is D: 'Stay upright after taking the medication.' This instruction is crucial for clients receiving medications like bisphosphonates to prevent esophageal irritation or erosion. While weight-bearing exercises (choice A) are important for bone health, staying upright after medication intake takes precedence. Increasing calcium-rich foods (choice B) is beneficial but not the most important immediate instruction. Scheduling bone density tests (choice C) is necessary for monitoring osteoporosis but is not as critical as staying upright after medication.

4. A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?

• A. Monitor for signs of autonomic dysreflexia.
• B. Implement measures to prevent pressure ulcers.
• C. Perform passive range of motion exercises.
• D. Ensure that the client is turned every two hours.

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.

5. While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

• A. Ask the mother what she usually uses on the child's lips and nose.
• B. Apply a petroleum jelly (Vaseline) to the child's nose and lips.
• C. Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips.
• D. Use a water-soluble lubricant on affected oral and nasal mucosa.

Correct answer: D

Rationale: A water-soluble lubricant is safe to use in conjunction with oxygen therapy, unlike petroleum jelly which is flammable.

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