Nursing Elites

1. The client is diagnosed with pneumonia. Which intervention is most effective in promoting airway clearance?

• A. Administer bronchodilators as prescribed
• B. Encourage increased fluid intake
• C. Perform chest physiotherapy
• D. Provide humidified oxygen

Correct answer: B

Rationale: Encouraging increased fluid intake is the most effective intervention in promoting airway clearance for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making it easier for the client to clear the airways. Administering bronchodilators may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy may be beneficial but is not the first-line intervention for promoting airway clearance in pneumonia. Providing humidified oxygen can improve oxygenation but does not directly address airway clearance.

2. A client is admitted with diabetic ketoacidosis. What is the most critical treatment to initiate?

• A. Administer sodium bicarbonate IV
• B. Start an insulin drip
• C. Monitor glucose and ketone levels
• D. Provide oral hydration

Correct answer: B

Rationale: In the case of diabetic ketoacidosis, the most critical treatment to initiate is starting an insulin drip. Insulin therapy is crucial for reducing blood glucose levels by promoting glucose uptake in cells and inhibiting the production of ketones. Administering sodium bicarbonate IV is generally not recommended as it may lower the pH further and potentially worsen the condition. While monitoring glucose and ketone levels is important for assessing the response to treatment, initiating insulin therapy takes precedence. Providing oral hydration alone is insufficient to manage the metabolic derangements seen in diabetic ketoacidosis.

3. When inserting an indwelling urinary catheter in a female client and urine flows into the tubing, what is the next action?

• A. Document the color and clarity of the urine
• B. Insert the catheter an additional inch
• C. Ask the client to breathe deeply and slowly exhale
• D. Inflate the balloon with 5 mL of sterile water

Correct answer: D

Rationale: When urine flows into the tubing during the insertion of an indwelling urinary catheter, it confirms proper catheter placement. The next step should be to inflate the balloon with the specified amount of sterile water to secure the catheter in place. Documenting the color and clarity of the urine (choice A) is important for assessment but not the immediate next action. Inserting the catheter further (choice B) without securing it could cause harm. Asking the client to breathe deeply (choice C) is not relevant to this situation.

4. The healthcare provider is caring for a client with a chest tube following a pneumothorax. Which assessment finding should be reported to the healthcare provider immediately?

• A. Continuous bubbling in the water seal chamber
• B. Absence of drainage in the collection chamber
• C. Tidaling in the water seal chamber
• D. Presence of subcutaneous emphysema around the insertion site

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber should be reported to the healthcare provider immediately. This finding may indicate an air leak, which can compromise the effectiveness of the chest tube in re-expanding the lung. Absence of drainage in the collection chamber (choice B) may signify that the chest tube is blocked, but it does not pose an immediate threat to the client's condition. Tidaling in the water seal chamber (choice C) is an expected finding and indicates proper functioning of the chest tube system. Presence of subcutaneous emphysema around the insertion site (choice D) suggests air leakage but is not as urgent as continuous bubbling in the water seal chamber.

5. What is the primary function of neutrophils?

• A. Heparin secretion
• B. Transport oxygen
• C. Phagocytotic action
• D. Antibody formation

Correct answer: C

Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.

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