Nursing Elites

1. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

• A. The tube will drain fluid from your chest.
• B. The tube will remove excess air from your chest.
• C. The tube controls the amount of air that enters your chest.
• D. The tube will seal the hole in your lung.

Correct answer: B

Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.

2. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?

• A. As you urinate more, you will need less medication to control fluid.
• B. You will have to take this medication for about a year.
• C. The medication must be continued so the fluid problem is controlled.
• D. Please talk to your health care provider about medications and treatments.

Correct answer: C

Rationale: Diuretics must be continued to control fluid retention, as stopping them can lead to worsening of congestive heart failure.

3. A nurse is assisting with the development of strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select one that doesn't apply).

• A. Avoid unpasteurized dairy products.
• B. Keep cold food temperatures below 4.4°C (40°F).
• C. Discard leftovers after 48 hours.
• D. Wash raw vegetables thoroughly in clean water.

Correct answer: C

Rationale: The correct answer is C. Discarding leftovers after 48 hours is not an effective recommendation to prevent foodborne illnesses. Leftovers should actually be discarded within 2 hours if they have been at room temperature. Choices A, B, and D are all effective strategies to prevent foodborne illnesses: avoiding unpasteurized dairy products reduces the risk of harmful bacteria, keeping cold food temperatures below 4.4°C (40°F) inhibits bacterial growth, and washing raw vegetables thoroughly removes contaminants.

4. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.

5. A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?

• A. Eating yogurt can help decrease gas odor that I have.
• B. I should eliminate pasta from my diet so that I don't have as many loose stools.
• C. My largest meal of the day should be in the evening.
• D. Carbonated beverages can help control odor.

Correct answer: A

Rationale: The correct answer is A. Yogurt contains probiotics which can help reduce gas and odor in colostomy patients. Choice B is incorrect because pasta is a low-fiber food that can help thicken stools, which may be beneficial for colostomy patients. Choice C is incorrect because it is generally recommended for colostomy patients to have their largest meal earlier in the day to allow for better digestion. Choice D is incorrect because carbonated beverages can actually increase gas production and worsen odor in colostomy patients.

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