Nursing Elites

1. A client is admitted to the postoperative surgical unit with two test tubes after a left lobectomy. The nurse observed that the chambers are set at the prescribed suction of 20 cm water pressure, and tidying occurs with respirations and bubbling. What action should the nurse implement?

• A. Clamp the chest tube to see if the bubbling activity stops
• B. Notify the registered nurse of the observed bubbling
• C. Maintain system integrity to promote lung reexpansion
• D. Apply an occlusive dressing to the chest

Correct answer: C

Rationale: Maintaining system integrity is essential to promote lung reexpansion in postoperative patients with chest tubes. Clamping the chest tube abruptly can lead to tension pneumothorax, a life-threatening condition. The bubbling observed is a normal sign indicating that the system is functioning correctly, as it allows the drainage of air or fluid from the pleural space. Notifying the registered nurse may be necessary if there are significant concerns or changes observed, but the immediate action should be to ensure system integrity and lung reexpansion.

2. Which electrolyte imbalance is most commonly associated with seizures?

• A. Hyponatremia
• B. Hypercalcemia
• C. Hyperkalemia
• D. Hypokalemia

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.

3. A dispersion consists of a solute dispersed through a dispersing vehicle. Which of the following dispersions is a liquid for topical application that contains insoluble solids or liquids?

• A. Ointment
• B. Lotion
• C. Paste
• D. Gel

Correct answer: B

Rationale: The correct answer is B, 'Lotion.' A lotion is a liquid dispersion that contains insoluble solids or liquids for topical application. Ointments are more semi-solid and occlusive, pastes are thicker and contain higher concentrations of solids, and gels have a jelly-like consistency due to their three-dimensional network structure. Therefore, among the options, a lotion is the most suitable choice for containing insoluble solids or liquids for topical application.

4. A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?

• A. Take all prescribed antibiotics as directed.
• B. Avoid crowded places and people who are sick.
• C. Wash hands frequently and practice good hygiene.
• D. Keep the surgical site clean and dry.

Correct answer: C

Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (Choice A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (Choice B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (Choice D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.

5. You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?

• A. 10
• B. 8
• C. 7
• D. 9

Correct answer: D

Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.

Similar Questions