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. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

• A. Avoid crossing your legs at the knees or ankles.
• B. Do not sleep on the side of the hip that was operated on.
• C. Sit in high chairs and keep your knees higher than your hips.
• D. Do not bend forward at the waist to pick up objects.

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

3. In which type of cardiomyopathy does septal involvement occur?

• A. Congestive
• B. Dilated
• C. Hypertrophic
• D. Restrictive

Correct answer: C

Rationale: Septal involvement is a characteristic feature of hypertrophic cardiomyopathy, where the septal wall of the heart thickens. This thickening can obstruct blood flow out of the heart, leading to complications such as arrhythmias and heart failure. This differentiates it from other types of cardiomyopathy. In congestive cardiomyopathy (choice A), the heart's chambers become enlarged and weakened, but there is no specific mention of septal involvement. Dilated cardiomyopathy (choice B) involves dilation and impaired contraction of the heart chambers, not specifically septal thickening. Restrictive cardiomyopathy (choice D) is characterized by stiffening of the heart muscle, affecting its ability to fill properly, without direct involvement of the septum.

4. Which nursing intervention is most appropriate for managing delirium in an elderly patient?

• A. Keeping the room brightly lit
• B. Administering sedatives as needed
• C. Encouraging family presence
• D. Restricting fluids

Correct answer: C

Rationale: Encouraging family presence is the most appropriate intervention for managing delirium in elderly patients. This intervention provides orientation, reassurance, and comfort, which can help reduce confusion and anxiety, thus aiding in managing delirium. Keeping the room brightly lit (Choice A) may worsen delirium as it can disrupt the patient's sleep-wake cycle. Administering sedatives (Choice B) should be avoided unless absolutely necessary due to the risk of worsening delirium. Restricting fluids (Choice D) is not a recommended intervention for managing delirium, as hydration is important for overall patient well-being.

5. Which assessment finding would most likely indicate a complication of enteral tube feeding?

• A. Abdominal distension
• B. Weight gain
• C. Decreased bowel sounds
• D. Diarrhea

Correct answer: A

Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.

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