Nursing Elites

1. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Document the amount of drainage every eight hours
• B. Obtain samples of drainage for culture from the system
• C. Assess patient pain level associated with the chest tube
• D. Check the water-seal chamber for the correct fluid level

Correct answer: A

Rationale: The correct answer is to document the amount of drainage every eight hours. UAP education typically includes tasks related to documentation of intake and output. Obtaining samples of drainage for culture and assessing patient pain level are nursing responsibilities that require licensed nursing personnel's education and scope of practice. Checking the water-seal chamber for the correct fluid level also falls under the nursing role, as it involves monitoring and maintaining the chest tube system, which requires nursing knowledge and training.

2. For a patient who is blood type AB, which blood product can they receive?

• A. Plasma from a type B donor
• B. Whole blood from a type A donor
• C. Packed RBCs from a type O donor
• D. All of the above

Correct answer: C

Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.

3. When checking for proper blood pressure cuff size, which guideline is correct?

• A. The standard cuff size is appropriate for all sizes.
• B. The length of the rubber bladder should equal 80% of the arm circumference.
• C. The width of the rubber bladder should equal 80% of the arm circumference.
• D. The width of the rubber bladder should equal 40% of the arm circumference.

Correct answer: D

Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.

4. Who should be members of a patient care conference?

• A. Doctors, nurses, and nursing assistants since they are healthcare providers
• B. Doctors, nurses, and the patient and/or the family members
• C. ALL members of the healthcare team
• D. ALL members of the healthcare team and the patient/resident

Correct answer: D

Rationale: In a patient care conference, it is essential to have all members of the healthcare team present to ensure comprehensive and coordinated care. Including the patient or resident, along with their family members if desired, is crucial as they are the focus of care. Choice A is incorrect because it excludes other important members of the healthcare team. Choice B is partially correct as it includes the patient and/or family members but does not encompass the entire healthcare team. Choice C is too broad and does not specifically address the inclusion of the patient or resident. The correct answer, Choice D, includes all healthcare team members and the patient/resident, ensuring a holistic approach to patient-centered care.

5. After receiving change-of-shift report, which patient should the nurse assess first?

• A. A patient with pneumonia who has crackles in the right lung base
• B. A patient with possible lung cancer who has just returned after bronchoscopy
• C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
• D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

Correct answer: B

Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.

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