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 pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?

• A. Tissue sloughing upon extravasation
• B. Elevated blood pressure and heart rate
• C. Tinnitus and vertigo
• D. Erythema of the face, neck, and chest

Correct answer: C

Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.

3. A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?

• A. Ask the client to complete a food diary for the last 3 days
• B. Review the client’s lab data to determine her TSH, T3, and T4 levels
• C. Interview the client about her use of laxatives and diuretics
• D. Encourage the client to describe her daily exercise regimen

Correct answer: C

Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.

4. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

• A. Administer the prescribed amiodarone (Cordarone) immediately
• B. Institute a daily fluid restriction while the client is in the hospital
• C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
• D. Place the client in the Trendelenburg position to facilitate perfusion

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

5. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?

• A. Ensure the client remains NPO until all samples are collected
• B. Transport the sputum container to the laboratory in a biohazard bag
• C. Discard the initial sample and document the time it was obtained
• D. Document the time the client last ate or drank on the laboratory slip

Correct answer: B

Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.

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