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. A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?

• A. Place your baby's crib away from heat vents
• B. Place the crib close to a heater
• C. Place the crib near a window
• D. Place soft toys in the crib

Correct answer: A

Rationale: The correct answer is A: 'Place your baby's crib away from heat vents.' Placing the crib away from heat vents is essential to prevent the baby from becoming overheated and to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice B is incorrect because placing the crib close to a heater increases the risk of overheating and poses a fire hazard. Choice C is incorrect as placing the crib near a window exposes the baby to drafts and temperature fluctuations. Choice D is incorrect as soft toys in the crib can pose a suffocation risk to the newborn.

3. A nurse is reviewing the plan of care for a client who is undergoing total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor the client's electrolyte levels daily
• B. Weigh the client daily
• C. Monitor the client's blood glucose levels every 6 hours
• D. Change the TPN tubing every 24 hours

Correct answer: D

Rationale: The correct intervention for the nurse to include in the plan of care for a client undergoing total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. Changing the tubing at regular intervals helps reduce the risk of infection associated with central venous catheters. Monitoring electrolyte levels daily (Choice A) is important but not specific to TPN. Weighing the client daily (Choice B) is important for monitoring fluid status but not directly related to TPN. Monitoring blood glucose levels every 6 hours (Choice C) is essential for clients receiving TPN, but changing the tubing is a more critical intervention to prevent infections.

4. A nurse is reinforcing teaching with a client who has fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving?

• A. Cherry tomatoes
• B. Potatoes
• C. Spinach
• D. Cucumber slices

Correct answer: D

Rationale: The correct answer is D, cucumber slices. Cucumbers have the highest water content per 1 cup serving among raw vegetables, making them an excellent choice for a client with fluid volume deficit. Cherry tomatoes (choice A), potatoes (choice B), and spinach (choice C) do not have as high water content as cucumbers and therefore are not the best choice for increasing fluid intake.

5. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect?

• A. Polyuria.
• B. Dehydration.
• C. Hyponatremia.
• D. Hyperglycemia.

Correct answer: C

Rationale: The correct answer is C: Hyponatremia. In SIADH, there is excessive release of antidiuretic hormone, causing water retention and dilutional hyponatremia. Polyuria (choice A) is increased urination, which is not a typical finding in SIADH. Dehydration (choice B) is the loss of body fluids, which is opposite to the fluid retention seen in SIADH. Hyperglycemia (choice D) is elevated blood sugar levels and is not directly related to SIADH.

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