Nursing Elites

1. 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.

2. A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment finding is most often associated with hyperthyroidism?

• A. Periorbital edema.
• B. Atrophied thyroid gland.
• C. Increased pulse rate.
• D. Diarrhea stools.

Correct answer: C

Rationale: Increased pulse rate is commonly associated with hyperthyroidism due to the increased metabolic rate. Periorbital edema (Choice A) is more commonly associated with conditions like nephrotic syndrome or heart failure, not hyperthyroidism. Atrophied thyroid gland (Choice B) is not typically an assessment finding for hyperthyroidism as the gland is usually enlarged in this condition. Diarrhea stools (Choice D) can occur in hyperthyroidism, but it is not the most common assessment finding associated with the condition.

3. The client with chronic renal failure is receiving instruction on dietary restrictions. Which of the following food items should the client be instructed to avoid?

• A. Bananas.
• B. Apples.
• C. Rice.
• D. Potatoes.

Correct answer: A

Rationale: The correct answer is A: Bananas. Bananas are high in potassium, and individuals with chronic renal failure are often advised to limit potassium intake to prevent hyperkalemia. Apples, rice, and potatoes are lower in potassium and can be included in moderation in the diet of clients with chronic renal failure.

4. A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client’s neck primarily because:

• A. It is unnecessary to use both hands
• B. Feeling dual pulsations may lead to an incorrect measurement
• C. Palpating both carotid pulses simultaneously could occlude the trachea
• D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

Correct answer: D

Rationale: The correct answer is D. Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. Palpating both carotid pulses simultaneously could also interfere with the flow of blood to the brain, possibly causing dizziness and syncope. Choices A, B, and C are incorrect. It is necessary to use both hands to measure the carotid pulse accurately. Feeling dual pulsations does not lead to an incorrect measurement, and palpating both carotid pulses simultaneously does not occlude the trachea.

5. A client who experienced partial-thickness burns involving over 50% body surface area (BSA) 2 weeks ago has several open wounds and develops watery diarrhea. The client's blood pressure is 82/40 mmHg, and temperature is 96°F (36.6°C). Which action is most important for the nurse to take?

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In this scenario, the client is presenting with signs of sepsis, such as hypotension, hypothermia, and a recent history of partial-thickness burns with open wounds. The development of watery diarrhea further raises suspicion for sepsis. With a blood pressure of 82/40 mmHg and a low temperature of 96°F (36.6°C), the nurse should recognize the potential for septic shock. Notifying the rapid response team is crucial in this situation as the client requires immediate intervention and management to prevent deterioration and address the underlying septic process. Increasing the room temperature (Choice A) is not the priority as the low body temperature is likely due to systemic vasodilation and not environmental factors. While assessing oxygen saturation (Choice B) is important, the client's hypotension and hypothermia take precedence. Continuing to monitor vital signs (Choice C) alone is insufficient given the critical condition of the client and the need for prompt action to address the sepsis and potential septic shock.

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