Nursing Elites

1. During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?

• A. Continuous bubbling in the water seal chamber
• B. Gentle constant bubbling in the suction control chamber
• C. Drainage system positioned upright at chest level
• D. Exposed sutures without dressing

Correct answer: B

Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.

2. Palpating the midclavicular line is the correct technique for assessing

• A. Baseline vital signs
• B. Systolic blood pressure
• C. Respiratory rate
• D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

3. If a patient's blood pressure is 150/96, what is his pulse pressure?

• A. 54
• B. 96
• C. 150
• D. 246

Correct answer: A

Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, the systolic pressure is 150 and the diastolic pressure is 96. Therefore, the pulse pressure is 150 - 96 = 54. Pulse pressure represents the force generated by the heart with each contraction and is an important indicator of cardiovascular health.

4. A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the professional take to identify the client?

• A. Match the client's blood type with the type and cross-match specimens
• B. Confirm the provider's prescription matches the number on the blood component
• C. Ask the client to state their blood type and the date of their last blood donation
• D. Ensure that the client's identification band matches the number on the blood unit

Correct answer: A

Rationale: When preparing to administer an autologous blood product, it is crucial to correctly identify the client to prevent errors. Matching the client's blood type with the type and cross-match specimens ensures that the blood product is intended for the correct recipient. This step helps in verifying the patient's identity and avoiding any transfusion-related complications. Confirming the blood type through type and cross-matching is a standard practice to ensure patient safety during blood transfusions.

5. A caregiver is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The caregiver asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the caregiver make?

• A. Your baby needs an IV because she is not producing any tears
• B. Your baby needs an IV because her fontanels are bulging
• C. Your baby needs an IV because she is breathing slower than normal
• D. Your baby needs an IV because her heart rate is decreasing

Correct answer: A

Rationale: The correct response is A: 'Your baby needs an IV because she is not producing any tears.' In infants, the inability to produce tears is a sign of severe dehydration. This is a crucial indication for the need for intravenous (IV) fluid therapy to rehydrate the infant. While the other options may also be symptoms of dehydration, the absence of tears is a more direct and specific indicator requiring immediate attention and intervention.

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