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. What is the first action to take for a patient experiencing a seizure?

• A. Administer anticonvulsant medication
• B. Protect the patient's head
• C. Insert an oral airway
• D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

3. A client at 10 weeks of gestation with a history of UTIs is receiving teaching from a nurse. Which of the following statements should the nurse include?

• A. You should drink 240 ml (8 oz) of water before and after intercourse.
• B. You should avoid drinking orange juice because it increases the risk of infection.
• C. You should empty your bladder after intercourse to help prevent infection.
• D. You should take a hot bath to help prevent infection.

Correct answer: C

Rationale: The correct statement the nurse should include is to advise the client to empty their bladder after intercourse to help prevent UTIs. Emptying the bladder after intercourse helps reduce the risk of UTIs by flushing bacteria from the urethra. Choice A is incorrect as drinking water before and after intercourse is not specifically related to preventing UTIs. Choice B is incorrect as there is no direct correlation between orange juice consumption and UTI risk. Choice D is incorrect as taking a hot bath can actually increase the risk of UTIs by promoting bacterial growth.

4. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

• A. Hgb 10 g/dL
• B. Platelets 300,000/mm³
• C. WBC count 12,000/mm³
• D. BUN 18 mg/dL

Correct answer: A

Rationale: The correct answer is A: Hgb 10 g/dL. A hemoglobin level of 10 g/dL is below the normal range for a pregnant client, indicating possible anemia, which is crucial to report during pregnancy to prevent complications for both the mother and the baby. Platelets, WBC count, and BUN levels within the listed values are generally within normal ranges for a pregnant individual at 28 weeks of gestation. Platelets play a role in blood clotting, WBC count helps in fighting infections, and BUN measures kidney function, all of which are typically expected to be within normal limits during pregnancy.

5. A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?

• A. Use a cuff that is too loose for the arm.
• B. Place the cuff over clothing.
• C. Sit quietly for 5 minutes before measuring your blood pressure.
• D. Use the same arm for each reading.

Correct answer: C

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.

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