Nursing Elites

1. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Constant bubbling in the water seal chamber.
• B. Intermittent bubbling in the suction control chamber.
• C. Tidaling in the water seal chamber.
• D. Drainage of 75 mL in the first 24 hours.

Correct answer: A

Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.

2. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?

• A. Leaving a nasogastric tube clamped after administering oral medication.
• B. Documenting communication with a provider in the progress notes of the client's medical records.
• C. Administering potassium via IV bolus.
• D. Placing a yellow bracelet on a client who is at risk for falls.

Correct answer: C

Rationale: Administering potassium via IV bolus is a malpractice issue due to the risk of cardiac complications. Option A is incorrect as leaving a nasogastric tube clamped after administering oral medication can lead to complications but is not directly linked to malpractice. Option B is incorrect as documenting communication with a provider in the progress notes is a necessary part of nursing practice. Option D is incorrect as placing a yellow bracelet on a client at risk for falls is a safety measure to prevent falls and is not related to malpractice issues.

3. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min
• B. White blood cell count of 9,000/mm3
• C. Temperature of 37.8°C (100°F)
• D. Blood pressure of 118/78 mm Hg

Correct answer: C

Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.

4. A healthcare provider is assessing a newborn who has a patent ductus arteriosus. Which of the following findings should the provider expect?

• A. Continuous murmur.
• B. Absent peripheral pulses.
• C. Increased blood pressure.
• D. Bounding pulses.

Correct answer: A

Rationale: A continuous murmur is a classic finding in a newborn with patent ductus arteriosus. This murmur is typically heard between the first and second heart sounds and throughout systole. Absent peripheral pulses (choice B) are not typically associated with patent ductus arteriosus. Increased blood pressure (choice C) and bounding pulses (choice D) are not commonly seen with this condition. Therefore, the correct answer is A.

5. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place a sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.

Similar Questions