Nursing Elites

1. The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

• A. Fluctuation of the fluid level within the water seal chamber
• B. Absence of fluid in the drainage tubing
• C. Continuous bubbling within the water seal chamber
• D. Equal amounts of fluid drainage in each collection chamber

Correct answer: A

Rationale: Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.

2. A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

• A. Blockage of the ET tube by the client's tongue
• B. Passage of the ET tube into the esophagus
• C. Movement of the ET tube into the right main bronchus
• D. Infection of the vocal cords

Correct answer: C

Rationale: When the nurse observes the absence of left-sided chest wall expansion upon respiration, it indicates that the endotracheal tube (ET) may have migrated into the right main bronchus, leading to uneven chest expansion. This can result in inadequate ventilation to the left lung, causing respiratory compromise. The other options, such as blockage of the ET tube by the client's tongue, passage of the ET tube into the esophagus, and infection of the vocal cords, do not directly explain the observed chest wall asymmetry and respiratory distress.

3. A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?

• A. Stridor
• B. Copious oral secretions
• C. Hoarseness
• D. Sore throat

Correct answer: A

Rationale: Stridor is a high-pitched, harsh respiratory sound that can indicate airway obstruction. It is a serious finding that requires immediate attention as it may lead to respiratory compromise. Copious oral secretions, hoarseness, and sore throat are common but expected findings after endotracheal tube removal and do not typically require urgent intervention.

4. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

• A. Restrict the client's fluid intake.
• B. Assess the client's respiratory status.
• C. Administer diuretics as ordered.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

5. A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?

• A. Ask the hospitals there about standard nurse-client ratios.
• B. Choose the hospital that has the newest technology.
• C. Find a hospital that is accredited by The Joint Commission.
• D. Use a facility affiliated with a medical or nursing school.

Correct answer: C

Rationale: Choosing a hospital accredited by The Joint Commission (TJC) or another accrediting body is the best advice as it ensures a focus on safety and quality standards.

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