Nursing Elites

1. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

2. What are the nursing interventions for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Administer antiplatelet therapy
• C. Check for signs of DVT and provide anticoagulation
• D. Administer aspirin and monitor for bleeding

Correct answer: A

Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.

3. A patient is being educated about a clear liquid diet. Which of the following should the nurse instruct the patient to avoid?

• A. Lemon-lime sports drinks
• B. Ginger ale
• C. Black coffee
• D. Orange sherbet

Correct answer: D

Rationale: The correct answer is D: Orange sherbet. A clear liquid diet consists of liquids that are transparent and easily digestible. Orange sherbet, being a frozen dessert, is not a clear liquid and should be avoided. Choices A, B, and C are all acceptable in a clear liquid diet. Lemon-lime sports drinks, ginger ale, and black coffee are clear liquids that can be included in the diet as they are transparent and leave little residue in the gastrointestinal tract, unlike orange sherbet.

4. A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

• A. Low birth weight
• B. Advanced maternal age
• C. Single parenthood
• D. Premature birth

Correct answer: A

Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.

5. A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

• A. Request an occupational therapy consult to determine the need for assistive devices
• B. Assign assistive personnel to perform self-care tasks for the client
• C. Instruct the client to focus on gradually resuming self-care tasks
• D. Ask the client if a family member is available to assist with his care

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence following an acute myocardial infarction. This approach allows the client to regain confidence and control over their self-care activities without feeling overwhelmed. Requesting an occupational therapy consult (Choice A) may be beneficial but is not the immediate solution to promote independence. Assigning assistive personnel (Choice B) to perform tasks for the client does not encourage independence. Asking if a family member is available for assistance (Choice D) does not directly promote the client's independence.

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