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 nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary modifications. Which food should the client avoid?

• A. Applesauce
• B. White rice
• C. Coffee
• D. Bananas

Correct answer: C

Rationale: The correct answer is C: Coffee. Coffee should be avoided by clients with GERD as it can relax the lower esophageal sphincter, leading to an increase in GERD symptoms. Choices A, B, and D are not directly associated with worsening GERD symptoms and can be included in moderation in the diet of a client with GERD.

3. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia. Which finding should the nurse document in the EMR as a therapeutic response to the lidocaine infusion?

• A. Stabilization of BP ranges
• B. Cessation of chest pain
• C. Reduced heart rate
• D. Decreased frequency of episodes of VT

Correct answer: D

Rationale: The correct answer is D. Decreased frequency of ventricular tachycardia (VT) episodes indicates that the lidocaine infusion is effectively managing the ventricular tachycardia. Stabilization of BP ranges (choice A) may not directly correlate with the therapeutic response to lidocaine for VT. Cessation of chest pain (choice B) may indicate pain relief but does not specifically address the effectiveness of lidocaine for VT. Reduced heart rate (choice C) is not a direct indicator of the response to lidocaine for managing VT.

4. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?

• A. Drowsiness
• B. Gingival hyperplasia
• C. Weight gain
• D. Blurred vision

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.

5. A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?

• A. Osmolarity
• B. Glucose
• C. Albumin
• D. Platelets

Correct answer: B

Rationale: The correct answer is B: Glucose. Hydrocortisone can lead to increased blood glucose levels, so monitoring glucose is crucial to assess for hyperglycemia, a common side effect of corticosteroid therapy. Monitoring osmolarity (choice A) is not typically indicated in this scenario. Albumin (choice C) and platelets (choice D) are not directly affected by hydrocortisone therapy and are not the primary focus of monitoring in this case.

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