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 is the correct intervention for a patient experiencing anaphylaxis?

• A. Administer epinephrine
• B. Provide oxygen
• C. Monitor airway
• D. All of the above

Correct answer: D

Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.

3. What are the signs of hypovolemic shock and what is the nurse's role in management?

• A. Rapid pulse, low blood pressure; administer IV fluids
• B. Cold extremities, rapid breathing; administer oxygen
• C. Decreased urine output, sweating; administer diuretics
• D. Weak pulse, clammy skin; administer vasopressors

Correct answer: A

Rationale: The correct signs of hypovolemic shock are a rapid pulse and low blood pressure. Administering IV fluids helps to restore circulating volume, which is essential in managing hypovolemic shock. Choice B is incorrect because cold extremities and rapid breathing are not typical signs of hypovolemic shock. Choice C is incorrect as administering diuretics would further decrease circulating volume, worsening the condition. Choice D is incorrect as administering vasopressors may further compromise perfusion in hypovolemic shock.

4. A nurse is providing discharge instructions for a client with diabetes. What is the most important teaching point?

• A. Monitor blood sugar levels weekly
• B. Administer insulin before meals as prescribed
• C. Take medication only when feeling unwell
• D. Monitor blood sugar only in the morning

Correct answer: B

Rationale: The correct answer is B: Administer insulin before meals as prescribed. This is the most important teaching point because insulin administration before meals helps manage blood sugar effectively in diabetic patients. Choice A is incorrect because monitoring blood sugar levels weekly may not provide timely information for managing diabetes. Choice C is incorrect as medications for diabetes should be taken as prescribed, not only when feeling unwell. Choice D is incorrect as blood sugar levels should be monitored at various times throughout the day, not just in the morning, to get a complete picture of the patient's condition.

5. How should a healthcare professional assess and manage a patient with dehydration?

• A. Assess skin turgor and monitor intake/output
• B. Encourage oral fluids only
• C. Administer IV fluids immediately
• D. Check for electrolyte imbalance and administer fluids

Correct answer: A

Rationale: The correct way to assess and manage a patient with dehydration is to assess skin turgor and monitor intake/output. Skin turgor assessment helps in evaluating the degree of dehydration, while monitoring intake/output aids in maintaining fluid balance. Encouraging oral fluids only (Choice B) may not be sufficient for moderate to severe dehydration as patients may need intravenous fluids (IV) to rapidly rehydrate. Administering IV fluids immediately (Choice C) is not always the first step unless the patient is severely dehydrated. Checking for electrolyte imbalance and administering fluids (Choice D) is important but comes after assessing skin turgor and intake/output in the management of dehydration.

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