Nursing Elites

1. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Monitor urine output hourly
• B. Assess for back muscle aches
• C. Record drainage from the drain
• D. Obtain body weight daily

Correct answer: C

Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.

2. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?

• A. Ambulate with a walker for upper body support
• B. Perform abdominal curls to stretch the back muscles
• C. Position in semi-Fowler's with the knees flexed
• D. Encourage straight leg raises while lying supine

Correct answer: C

Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.

3. The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
• B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills

Correct answer: C

Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.

4. A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply)

• A. Encourage oral fluid intake of 3,000 ml/day
• B. Observe for evidence of hypokalemia
• C. Teach the client how to restrict dietary sodium
• D. Monitor PTT, PT, and INR lab values

Correct answer: B

Rationale: The correct interventions to include when a client with heart failure is being treated with diuretics for fluid volume excess are to observe for evidence of hypokalemia. Diuretics can lead to potassium loss, resulting in hypokalemia. Monitoring for this electrolyte imbalance is crucial. Encouraging oral fluid intake of 3,000 ml/day may exacerbate fluid volume excess in a client with heart failure. Teaching the client how to restrict dietary sodium is important in managing heart failure, but it is not directly related to the use of diuretics for fluid volume excess. Monitoring PTT, PT, and INR lab values is not typically associated with diuretic therapy for heart failure but rather with anticoagulant therapy.

5. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?

• A. Headache
• B. Pruritus
• C. Nausea
• D. Stridor

Correct answer: D

Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.

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