Nursing Elites

1. A client who had a radical neck dissection returns to the surgical unit with 2 JP drains in the right side of the incision. One JP tube is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP?

• A. Reinforce the incisional dressings and assess behind the neck for drainage.
• B. Place the client in a right lateral side-lying position and elevate the head of the bed.
• C. Irrigate the JP tubing with 1 ml NSS, then close the opening with its tab.
• D. Compress the bulb with the tab open and then reinsert the tab into its opening.

Correct answer: D

Rationale: Compressing the bulb with the tab open creates suction, which helps increase drainage into the JP drain. This action can aid in removing accumulated fluids from the surgical site. Reinforcing the incisional dressings and assessing behind the neck for drainage (Choice A) is not directly related to increasing drainage into the JP. Placing the client in a right lateral side-lying position and elevating the head of the bed (Choice B) may not directly impact drainage into the JP drain. Irrigating the JP tubing with 1 ml NSS and then closing the opening with its tab (Choice C) is unnecessary and could introduce contaminants into the drain.

2. The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?

• A. 50 ml/hour.
• B. 75 ml/hour.
• C. 100 ml/hour.
• D. 125 ml/hour.

Correct answer: C

Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.

3. A client with peptic ulcer disease is prescribed sucralfate. What is the mechanism of action of this medication?

• A. Neutralizes stomach acid
• B. Decreases gastric acid secretion
• C. Covers the ulcer site and protects it from acid
• D. Improves gastric motility

Correct answer: C

Rationale: The correct answer is C: Covers the ulcer site and protects it from acid. Sucralfate works by forming a protective barrier over ulcers, shielding them from stomach acid and promoting healing. Choice A, neutralizing stomach acid, is incorrect as sucralfate does not neutralize acid but acts as a physical barrier. Choice B, decreasing gastric acid secretion, is not the mechanism of action of sucralfate. Choice D, improving gastric motility, is unrelated to sucralfate's action on peptic ulcers.

4. During the initial assessment of an older male client with obesity and diabetes who develops intermittent claudication, which additional information obtained by the nurse is most significant?

• A. Smokes 1.5 packs of cigarettes daily.
• B. Exercises regularly.
• C. Has a high-fat diet.
• D. Consumes alcohol daily.

Correct answer: A

Rationale: The correct answer is A: 'Smokes 1.5 packs of cigarettes daily.' Smoking is a significant risk factor for peripheral arterial disease, a condition that can lead to intermittent claudication. The nicotine and other chemicals in cigarettes can damage blood vessels, leading to reduced blood flow and increased risk of developing circulation problems. Choices B, C, and D are less significant in the context of intermittent claudication. Regular exercise, a high-fat diet, and daily alcohol consumption may have health implications, but they are not as directly linked to the development of intermittent claudication in the presence of obesity, diabetes, and smoking.

5. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

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