Nursing Elites

1. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?

• A. Instruct the client to perform cough and deep breathing exercises
• B. Assess the client’s vital signs and respiratory effort
• C. Administer oxygen via nasal cannula according to the PNR protocol
• D. Document assessment findings in the client’s medical record

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.

2. Which type of wound would most likely require immediate intervention by the healthcare provider?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: A laceration would most likely require immediate intervention by the healthcare provider due to its deeper tissue damage, significant bleeding, and higher risk of infection compared to abrasions, contusions, and ulcerations. Lacerations often need prompt attention to control bleeding, clean the wound, and reduce the risk of infection. Abrasions are superficial wounds that usually do not require urgent attention as they tend to heal well on their own with basic wound care. Contusions are bruises that typically resolve on their own without immediate intervention. Ulcerations are open sores that may require intervention but not necessarily immediate action unless complicated by infection or other issues.

3. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

• A. The client has asymmetrical chest wall expansion
• B. The client complains of pain at the insertion site
• C. The client's chest x-ray indicates decreased pleural effusion
• D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26

Correct answer: A

Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.

4. The public health nurse received funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal?

• A. Case management and screening for clients with HIV.
• B. Regional relocation center for earthquake victims.
• C. Vitamin supplements for high-risk pregnant women.
• D. Lead screening for children in low-income housing.

Correct answer: C

Rationale: The correct answer is C: Vitamin supplements for high-risk pregnant women. This option aligns with primary prevention by preventing deficiencies before they occur, which is a key aspect of primary prevention. Providing vitamin supplements to high-risk pregnant women can help prevent birth defects and complications. Choices A, B, and D do not align with primary prevention strategies. Case management and screening for clients with HIV (Choice A) is more of a secondary prevention strategy aimed at early detection and management. A regional relocation center for earthquake victims (Choice B) is focused on addressing the aftermath of a disaster rather than preventing it. Lead screening for children in low-income housing (Choice D) is more about early detection and intervention rather than primary prevention.

5. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

• A. Observe for an intradermal bleed after the antigen is injected
• B. Select an ID site using the volar surface of the forearm
• C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
• D. Ensure that the needle is inserted into the skin with the bevel up

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

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