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 plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?

• A. A 29-year-old client after a difficult vaginal delivery – Habit training
• B. A 58-year-old postmenopausal client who is not taking estrogen therapy – Electrical stimulation
• C. A 64-year-old female with Alzheimer’s-type senile dementia – Bladder training
• D. A 77-year-old female who has difficulty ambulating – Exercise therapy

Correct answer: B

Rationale: The correct pairing is a 58-year-old postmenopausal client who is not taking estrogen therapy with electrical stimulation. Electrical stimulation is used for clients with stress incontinence related to menopause and low estrogen levels. Exercise therapy improves pelvic wall strength and is not specifically for ambulation issues. Habit training is more effective for cognitively impaired clients, like those with Alzheimer's-type senile dementia. Bladder training requires the client to be alert, aware, and able to resist the urge to urinate, which may not be suitable for clients with cognitive impairments.

3. A client is being taught about self-catheterization in the home setting. Which statements should the nurse include in this client’s teaching? (Select all that apply.)

• A. Wash your hands before and after self-catheterization.
• B. Use lubricant on the tip of the catheter before insertion.
• C. A & B
• D. Self-catheterize at least twice a day or every 12 hours.

Correct answer: C

Rationale: In teaching a client about self-catheterization, it is essential to emphasize proper hand hygiene before and after the procedure to prevent infections. Using lubricant on the catheter helps with insertion and reduces discomfort. Therefore, statements A and B are correct and should be included in the client's teaching. Option D is incorrect because self-catheterization frequency should be individualized based on the client's needs, and a specific time frame like every 12 hours may not be suitable for everyone. Choosing a smaller lumen catheter is preferred over a larger one. Self-catheterization should not be limited to a specific time frame but should be based on the individual's needs and voiding patterns. Therefore, option C is the correct choice as it includes the two essential statements for teaching self-catheterization in the home setting.

4. When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

• A. Ensure oral suction is available.
• B. Maintain the client in a semi-Fowler's position.
• C. Provide frequent mouth care.
• D. Keep the room at a comfortable temperature.

Correct answer: A

Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.

5. A client is getting out of bed for the first time since surgery. The client complains of dizziness after the nurse raises the head of the bed. Which of the following actions should the nurse take first?

• A. Checking the client’s blood pressure
• B. Checking the oxygen saturation level
• C. Having the client take some deep breaths
• D. Lowering the head of the bed slowly until the dizziness is relieved

Correct answer: D

Rationale: When a client experiences dizziness after being positioned upright for the first time post-surgery, the initial action the nurse should take is to lower the head of the bed slowly until the dizziness subsides. This maneuver helps alleviate the dizziness by allowing the body to adapt gradually to the change in position. Subsequently, the nurse should assess the client's pulse and blood pressure. Checking the blood pressure is essential to evaluate the circulatory status and rule out orthostatic hypotension as a cause of dizziness. Checking the oxygen saturation level and having the client take deep breaths are not the priority in this scenario as the primary concern is addressing the circulatory issue causing dizziness, not a respiratory problem.

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