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. The client has been managing angina episodes with nitroglycerin. Which of the following indicates the drug is effective?

• A. Decreased chest pain.
• B. Increased blood pressure.
• C. Decreased blood pressure.
• D. Decreased heart rate.

Correct answer: A

Rationale: The correct answer is A: Decreased chest pain. Nitroglycerin is a vasodilator that works by decreasing myocardial oxygen consumption, which helps to reduce chest pain caused by angina. Therefore, a reduction in chest pain is a positive indicator of the drug's effectiveness. Choices B, C, and D are incorrect because nitroglycerin does not typically increase blood pressure or heart rate; instead, it often causes a decrease in blood pressure due to vasodilation and may cause a reflex tachycardia (increased heart rate) as a compensatory response to lowered blood pressure.

3. The nurse is preparing to administer doses of hydrochlorothiazide (HydroDIURIL) and digoxin (Lanoxin) to a patient who has heart failure. The patient reports having blurred vision. The nurse notes a heart rate of 60 beats per minute and a blood pressure of 140/78 mm Hg. Which action will the nurse take?

• A. Administer the medications and request an order for serum electrolytes.
• B. Give both medications and evaluate serum blood glucose frequently.
• C. Hold the digoxin and notify the provider.
• D. Hold the hydrochlorothiazide and notify the provider.

Correct answer: C

Rationale: In this scenario, the patient is experiencing symptoms of digoxin toxicity, such as blurred vision and bradycardia. When thiazide diuretics like hydrochlorothiazide are taken with digoxin, the patient is at risk of digoxin toxicity due to the potential for thiazides to cause hypokalemia. Therefore, the correct action for the nurse to take is to hold the digoxin and notify the provider. Administering the medications without addressing the potential toxicity could worsen the patient's condition. Requesting serum electrolytes (Choice A) may be necessary but holding the digoxin takes priority. Evaluating serum blood glucose (Choice B) is not relevant to the current situation. Holding hydrochlorothiazide (Choice D) is not the best option as the primary concern is the digoxin toxicity that needs to be addressed promptly.

4. The client is planning care for a client who is receiving hemodialysis. Which of the following interventions should be included in the plan of care?

• A. Administer anticoagulants to prevent clot formation.
• B. Monitor the client for signs of infection.
• C. Provide the client with a high-protein diet.
• D. Encourage the client to drink at least 2 liters of fluid daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients receiving hemodialysis because they are at an increased risk of infection due to the invasive nature of the procedure. Administering anticoagulants is not typically a part of the routine care for clients undergoing hemodialysis unless specifically prescribed. While a high-protein diet may be beneficial for some clients, it is not a specific intervention related to hemodialysis. Encouraging fluid intake must be individualized based on the client's fluid status and should not be a generalized recommendation for all clients receiving hemodialysis.

5. A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?

• A. Place the client on a cardiac monitor immediately.
• B. Teach the client to limit high-potassium foods.
• C. Continue to monitor the client’s intake and output.
• D. Ask to have the laboratory redraw the blood specimen.

Correct answer: A

Rationale: The best immediate action by the nurse in this situation is to place the client on a cardiac monitor immediately. A serum potassium level of 6.5 mmol/L indicates hyperkalemia, which can lead to life-threatening dysrhythmias. Monitoring the cardiac status is crucial to detect any potential arrhythmias promptly. Teaching the client to limit high-potassium foods (Choice B) may be important for long-term management, but it is not the priority at this moment. Continuing to monitor intake and output (Choice C) is important for assessing renal function but does not address the immediate risk of dysrhythmias. Asking to have the laboratory redraw the blood specimen (Choice D) is unnecessary since the current results indicate a critical situation that requires immediate action.

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