Nursing Elites

1. A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:

• A. The tube is patent
• B. There is probably a kink in the tubing
• C. Suction should be added to the system
• D. The client is retaining airway secretions

Correct answer: A

Rationale: The correct answer is A: 'The tube is patent.' When the fluid in the water seal chamber rises and falls during inspiration and expiration, it indicates that the chest tube is patent, allowing for proper drainage. Choice B is incorrect because a kink in the tubing would obstruct the flow of fluid, leading to abnormal fluctuations in the water seal chamber. Choice C is incorrect as adding suction to the system is not indicated based on the described finding. Choice D is incorrect as the rising and falling of fluid in the water seal chamber is not indicative of the client retaining airway secretions.

2. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?

• A. Position the client to lay on the surgical incision.
• B. Measure the specific gravity of the client’s urine.
• C. Administer intravenous pain medications.
• D. Assess the rate and quality of the client’s pulse.

Correct answer: D

Rationale: The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

3. The client has been receiving peritoneal dialysis. The nurse should assess the client for which of the following complications that is most likely to occur?

• A. Electrolyte imbalance
• B. Peritonitis
• C. Infection
• D. Hyperglycemia

Correct answer: B

Rationale: Peritonitis is the most likely complication to occur in clients receiving peritoneal dialysis due to the risk of infection. Peritonitis is a serious inflammation of the peritoneum lining the abdominal cavity, commonly caused by infection. While electrolyte imbalance and hyperglycemia are possible complications in some cases, peritonitis poses a more immediate and severe threat to the client's health. Infection is a general term that can encompass peritonitis but is not as specific as directly identifying peritonitis as the primary concern in this scenario.

4. A patient taking trimethoprim-sulfamethoxazole (TMP-SMX) to treat a urinary tract infection complains of a sore throat. The nurse will contact the provider to request an order for which laboratory test(s)?

• A. Complete blood count with differential
• B. Throat culture
• C. Urinalysis
• D. Coagulation studies

Correct answer: A

Rationale: When a patient taking trimethoprim-sulfamethoxazole (TMP-SMX) for a urinary tract infection presents with a sore throat, the nurse should request a complete blood count with differential. TMP-SMX can cause life-threatening adverse effects such as agranulocytosis, a condition characterized by a low white blood cell count, which can manifest as a sore throat. Ordering a complete blood count with differential helps assess the patient's white blood cell count to detect any potential serious adverse effects. Throat culture (Choice B) is not indicated unless there are specific signs of a throat infection. Urinalysis (Choice C) is not relevant for assessing a sore throat. Coagulation studies (Choice D) are not typically indicated for a sore throat symptom.

5. A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?

• A. Assessing the client’s chest for crepitus every 24 hours
• B. Taping the connections between the chest tube and the drainage system
• C. Adding 20 mL of sterile water to the suction control chamber every shift
• D. Recording the volume of secretions in the drainage collection chamber every 24 hours

Correct answer: B

Rationale: The correct action for the nurse to take in caring for a client with a chest tube connected to a closed chest drainage system is to tape the connections between the chest tube and the drainage system. This is done to prevent accidental disconnection, ensuring the system functions properly. Assessing the client’s chest for crepitus should be done more frequently than once every 24 hours to monitor for any air leaks. Adding sterile water to the suction control chamber is not necessary every shift; it should be done as needed to maintain the appropriate water level. Recording the volume of secretions in the drainage collection chamber should be done more frequently than every 24 hours, with hourly monitoring during the first 24 hours after insertion and every 8 hours thereafter to assess for changes or complications.

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