Nursing Elites

1. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete.
• B. Take all prescribed medications as directed.
• C. Schedule a follow-up appointment with the healthcare provider.
• D. Wear a mask when in public places.

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

2. A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)

• A. Raisin bran muffins
• B. Bowl of oatmeal
• C. Cup of raspberries
• D. Scrambled eggs

Correct answer: A

Rationale: A high-fiber diet is beneficial for managing hemorrhoids as it helps maintain bowel regularity. Raisin bran muffins are a good choice for breakfast as they are high in fiber. Oatmeal is also a high-fiber option that aids digestion and prevents constipation. Raspberries are rich in fiber and contribute to a high-fiber diet. Scrambled eggs, on the other hand, are not high in fiber and do not provide the necessary fiber content needed for managing hemorrhoids.

3. The healthcare provider is caring for a client with a chest tube following a pneumothorax. Which assessment finding should be reported to the healthcare provider immediately?

• A. Continuous bubbling in the water seal chamber
• B. Absence of drainage in the collection chamber
• C. Tidaling in the water seal chamber
• D. Presence of subcutaneous emphysema around the insertion site

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber should be reported to the healthcare provider immediately. This finding may indicate an air leak, which can compromise the effectiveness of the chest tube in re-expanding the lung. Absence of drainage in the collection chamber (choice B) may signify that the chest tube is blocked, but it does not pose an immediate threat to the client's condition. Tidaling in the water seal chamber (choice C) is an expected finding and indicates proper functioning of the chest tube system. Presence of subcutaneous emphysema around the insertion site (choice D) suggests air leakage but is not as urgent as continuous bubbling in the water seal chamber.

4. Which client assessment falls within the scope of practice for the practical nurse?

• A. An agitated client with bilateral wrist restraints
• B. New admission of a client with deep vein thrombosis
• C. Return of a post-anesthesia client following a colon resection
• D. Transfer of a client with sepsis from a long-term care facility

Correct answer: B

Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?

• A. Administer bronchodilator therapy as prescribed
• B. Encourage deep breathing and coughing exercises
• C. Position the client in a high-Fowler's position
• D. Increase the oxygen flow rate

Correct answer: C

Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing in COPD patients. While administering bronchodilator therapy as prescribed (Choice A) is important, it is not the priority in this scenario. Encouraging deep breathing and coughing exercises (Choice B) can be beneficial but do not take precedence over positioning for improved respiratory function. Increasing the oxygen flow rate (Choice D) can be considered after the initial positioning to relieve respiratory distress, making it a later intervention.

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