Nursing Elites

1. The nurse notes that a client who has undergone a thoracotomy has an increase in a large amount of dark red blood in the chest tube collection chamber. What action should the nurse take?

• A. Document the findings for this procedure as expected
• B. Notify the healthcare provider immediately
• C. Check the tube for kinks or dependent loops
• D. Increase the suction to the chest drainage system

Correct answer: B

Rationale: An increase in a large amount of dark red blood in the chest tube collection chamber may indicate active bleeding. The nurse should notify the healthcare provider immediately to address the situation promptly and prevent further complications. Documenting the findings without taking immediate action could delay necessary interventions. Checking the tube for kinks or dependent loops is a good practice but not the priority when dealing with a potentially life-threatening situation like active bleeding. Increasing the suction without healthcare provider's orders can lead to complications and is not appropriate in this scenario.

2. A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?

• A. Fever of 100.4°F
• B. Positive Chvostek's sign
• C. Increased joint pain
• D. Swelling in the joints

Correct answer: B

Rationale: A positive Chvostek's sign indicates hypocalcemia, which requires immediate intervention as it can lead to life-threatening complications. Fever, increased joint pain, and swelling in the joints are common symptoms in clients with rheumatoid arthritis but do not require immediate intervention like addressing hypocalcemia.

3. The nurse is assessing a client with left-sided heart failure. Which finding requires immediate intervention?

• A. Shortness of breath
• B. Jugular venous distention
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: Crackles in the lungs indicate pulmonary congestion in a client with left-sided heart failure and require immediate intervention to prevent respiratory failure. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potentially respiratory distress. Shortness of breath, jugular venous distention, and peripheral edema are common manifestations of heart failure but do not directly indicate acute respiratory compromise like crackles in the lungs do.

4. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

• A. Institute coughing and deep breathing protocols.
• B. Administer oxygen via nasal cannula.
• C. Prepare for intubation and mechanical ventilation.
• D. Increase IV fluids to improve hydration.

Correct answer: A

Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.

5. A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?

• A. Widening pulse pressure
• B. Sudden drop in heart rate
• C. A decrease in urine output
• D. Elevated blood pressure and widening pulse pressure

Correct answer: D

Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.

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