Nursing Elites

1. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

• A. Tidaling with spontaneous respirations
• B. Drainage collection chamber is 1/3 full
• C. 1 cm of water present in the water seal chamber
• D. Suction chamber pressure of -20 cm H2O

Correct answer: C

Rationale: The correct answer is C. There should be 2 cm of water in the water seal chamber of the chest tube system. A level of 1 cm may indicate a leak or compromised functionality that requires intervention. Choices A, B, and D are not findings that necessarily require immediate intervention. Tidaling with spontaneous respirations is an expected finding, the drainage collection chamber being 1/3 full is within normal limits, and a suction chamber pressure of -20 cm H2O indicates appropriate suction for chest drainage.

2. A client is being taught how to use a PCA pump postoperatively. Which statement indicates understanding?

• A. I should wait until the pain is severe before using the PCA pump.
• B. My family can press the button for me when I'm asleep.
• C. I will press the button when I start to feel pain.
• D. I will only press the button once per hour.

Correct answer: C

Rationale: The correct answer is C because the client should press the PCA pump button when they start to feel pain. This approach helps maintain pain control effectively. Choice A is incorrect because waiting for the pain to become severe before using the PCA pump can lead to inadequate pain management. Choice B is incorrect because only the client should operate the PCA pump to ensure the correct dosage is administered. Choice D is incorrect because the client should press the button as needed when experiencing pain, rather than limiting its use to once per hour.

3. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.

4. A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?

• A. Naloxone
• B. Epinephrine
• C. Atropine
• D. Diazepam

Correct answer: A

Rationale: Meperidine is an opioid analgesic that can cross the placenta and cause respiratory depression in the newborn. Naloxone is an opioid antagonist that is administered to reverse the effects of opioids. It is critical to have Naloxone available when opioids are administered during labor, especially close to delivery. Epinephrine is not used to counteract the effects of opioids but rather for managing severe allergic reactions or cardiac arrest. Atropine is used for specific conditions like bradycardia, not to counteract opioid effects. Diazepam is a benzodiazepine used for anxiety, seizures, and muscle spasms, not for reversing opioid effects.

5. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges
• B. Cleanse the wound with normal saline
• C. Don sterile gloves
• D. Determine the client's pain level

Correct answer: D

Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.

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