Nursing Elites

1. A nurse is assessing a client who has a chest tube and notes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client.
• B. Clamp the chest tube.
• C. Replace the drainage system.
• D. Apply a dressing over the insertion site.

Correct answer: D

Rationale: The correct action for the nurse to take when continuous bubbling is noted in the water seal chamber of a chest tube is to apply a dressing over the insertion site. Continuous bubbling indicates an air leak, and applying a dressing helps manage this issue by providing a seal. Clamping the chest tube or replacing the drainage system is not appropriate in this situation as it can lead to complications such as tension pneumothorax or inadequate drainage of the pleural space.

2. A nurse is caring for a client who has acute pancreatitis. Which of the following interventions should the nurse take?

• A. Encourage oral intake of clear liquids
• B. Administer an antiemetic before meals
• C. Insert a nasogastric tube for suction
• D. Place the client in a supine position

Correct answer: C

Rationale: In acute pancreatitis, the gastrointestinal tract needs to rest to reduce pancreatic enzyme secretion. Inserting a nasogastric tube for suction helps decompress the stomach and reduce stimulation of the pancreas. Encouraging oral intake of clear liquids (Choice A) or administering an antiemetic before meals (Choice B) may aggravate the condition by stimulating the pancreas. Placing the client in a supine position (Choice D) may not directly address the underlying issue of reducing pancreatic stimulation.

3. A nurse in a pediatric clinic is reviewing laboratory findings for a school-age child. Which of the following findings should the nurse report to the provider?

• A. Hgb 12.5 g/dL
• B. Platelets 250,000/mm3
• C. WBC 14,000/mm3
• D. Hct 40%

Correct answer: D

Rationale: The correct answer is D: 'Hct 40%'. An abnormal hematocrit (Hct) level can indicate various conditions such as dehydration, overhydration, or blood disorders, and requires immediate attention from the healthcare provider. Choices A, B, and C are within normal ranges and do not typically warrant immediate provider notification. Hgb 12.5 g/dL (Choice A) is a normal hemoglobin level, Platelets 250,000/mm3 (Choice B) is a normal platelet count, and WBC 14,000/mm3 (Choice C) is slightly elevated but not significantly high to require urgent reporting.

4. A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?

• A. Bradycardia.
• B. Tachycardia.
• C. Nausea.
• D. Blurred vision.

Correct answer: D

Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.

5. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?

• A. Use three-pronged grounded plugs
• B. Cover extension cords with a rug
• C. Check for tingling sensations around the cord to ensure the electricity is working
• D. Remove the plug from the socket by pulling the cord

Correct answer: A

Rationale: The correct answer is A: 'Use three-pronged grounded plugs.' This is important in preventing electrical fires as it provides a grounded connection, reducing the risk of electrical malfunctions. Choice B is incorrect because covering extension cords with a rug can lead to overheating and increase the risk of fire. Choice C is also incorrect as tingling sensations around a cord indicate an electrical hazard, not proper functioning. Choice D is incorrect as pulling the cord to remove a plug can damage the cord, leading to potential electrical dangers.

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