Nursing Elites

1. A nurse has a prescription to discontinue a client’s nasogastric tube. The nurse auscultates the client’s bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:

• A. Exhale during tube removal
• B. Bear down during tube removal
• C. Hold the breath during tube removal
• D. Breathe normally during tube removal

Correct answer: C

Rationale: The correct answer is to instruct the client to hold their breath during tube removal. This is because the airway may be temporarily obstructed during the removal process. By holding their breath, the client can help prevent aspiration or discomfort during the removal of the nasogastric tube. Choices A, B, and D are incorrect because exhaling, bearing down, or breathing normally during tube removal may not provide the necessary protection against aspiration or discomfort that holding the breath does.

2. The client is planning care for a client who is receiving hemodialysis. Which of the following interventions should be included in the plan of care?

• A. Administer anticoagulants to prevent clot formation.
• B. Monitor the client for signs of infection.
• C. Provide the client with a high-protein diet.
• D. Encourage the client to drink at least 2 liters of fluid daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients receiving hemodialysis because they are at an increased risk of infection due to the invasive nature of the procedure. Administering anticoagulants is not typically a part of the routine care for clients undergoing hemodialysis unless specifically prescribed. While a high-protein diet may be beneficial for some clients, it is not a specific intervention related to hemodialysis. Encouraging fluid intake must be individualized based on the client's fluid status and should not be a generalized recommendation for all clients receiving hemodialysis.

3. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?

• A. The ileostomy is draining blood-tinged urine.
• B. There is serous sanguineous drainage on the surgical dressing.
• C. The ileostomy stoma appears pale and cyanotic.
• D. Oxygen saturations are 92% on room air.

Correct answer: C

Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.

4. A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, the nurse should first assess:

• A. The client’s vital signs
• B. The amount of drainage
• C. The client’s lung sounds
• D. The chest tube connections

Correct answer: D

Rationale: The client’s dyspnea is most likely related to an air leak caused by a loose connection in the chest tube system. Checking the chest tube connections should be the initial action because correcting an air leak can quickly resolve the client's symptoms. If a leak is found and corrected, the dyspnea should improve. Assessing the client’s vital signs (Option A) is important, but addressing the potential cause of dyspnea takes precedence. Monitoring the amount of drainage (Option B) is necessary for assessing the client's overall condition, but in this case, the dyspnea is likely due to an air leak. Checking the client’s lung sounds (Option C) is essential for respiratory assessment, but addressing the air leak should be the immediate priority to ensure adequate lung expansion and oxygenation.

5. A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, 'The client will verbalize symptoms of pacemaker failure.' Which symptoms are most important to teach the client?

• A. Facial flushing.
• B. Fever.
• C. Pounding headache.
• D. Feelings of dizziness.

Correct answer: D

Rationale: The correct answer is 'D: Feelings of dizziness.' Feelings of dizziness may occur as a result of a decreased heart rate, leading to decreased cardiac output, which can be an indication of pacemaker failure. Teaching the client to recognize symptoms of decreased cardiac output, like dizziness, is crucial for early detection of pacemaker malfunction. Choices A, B, and C are less specific to pacemaker failure and are not commonly associated with this condition. Facial flushing, fever, and pounding headache are not typical signs of pacemaker failure and are not directly related to cardiac output, making them less relevant for teaching the client about pacemaker failure.

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