Nursing Elites

1. A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, the nurse should first assess:

• A. The client’s vital signs
• B. The amount of drainage
• C. The client’s lung sounds
• D. The chest tube connections

Correct answer: D

Rationale: The client’s dyspnea is most likely related to an air leak caused by a loose connection in the chest tube system. Checking the chest tube connections should be the initial action because correcting an air leak can quickly resolve the client's symptoms. If a leak is found and corrected, the dyspnea should improve. Assessing the client’s vital signs (Option A) is important, but addressing the potential cause of dyspnea takes precedence. Monitoring the amount of drainage (Option B) is necessary for assessing the client's overall condition, but in this case, the dyspnea is likely due to an air leak. Checking the client’s lung sounds (Option C) is essential for respiratory assessment, but addressing the air leak should be the immediate priority to ensure adequate lung expansion and oxygenation.

2. The patient is receiving acetazolamide (Diamox) for metabolic alkalosis and fluid overload. After taking the medication, the patient complains of right-sided flank pain. The nurse suspects that the patient has developed which condition?

• A. Gout
• B. Hemolytic anemia
• C. Metabolic acidosis
• D. Renal calculi

Correct answer: D

Rationale: The correct answer is D: Renal calculi. Acetazolamide, a carbonic anhydrase inhibitor, can lead to electrolyte imbalances and the formation of renal calculi. Right-sided flank pain is a classic symptom of renal calculi. Choices A, B, and C are incorrect. Gout is not typically associated with acetazolamide use. Hemolytic anemia and metabolic acidosis are not commonly linked to acetazolamide-induced side effects. Therefore, the patient's symptoms align more closely with the development of renal calculi.

3. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103°F (39.4°C), blood pressure of 90/70, pulse of 124 beats/minute, and respirations of 28 breaths/minute. When assessing the client, findings include mottled skin appearance and confusion. Which action should the nurse take first?

• A. Transfer the client to the ICU.
• B. Initiate an infusion of intravenous (IV) fluids.
• C. Assess the client's core temperature.
• D. Obtain a wound specimen for culture.

Correct answer: B

Rationale: Initiating an infusion of IV fluids is the priority action to stabilize blood pressure in a client with signs of sepsis. Intravenous fluids help maintain perfusion to vital organs and prevent further deterioration. Option A is not the immediate priority as stabilizing the client's condition can be initiated in the current setting. Option C, assessing the client's core temperature, is important but not the most critical action at this time. Option D, obtaining a wound specimen for culture, is important for identifying the causative organism but is not the first priority in managing a client with signs of sepsis.

4. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?

• A. Report the findings to the surgeon.
• B. Irrigate the indwelling urinary catheter.
• C. Apply manual pressure to the bladder.
• D. Increase the IV flow rate for 15 minutes.

Correct answer: A

Rationale: In this situation, the nurse's priority action should be to report the findings to the surgeon. An adult should typically produce about 60 ml of urine per hour, so a dark, concentrated, and low urine output of 54 ml over 2 hours raises concerns. This change in urine output may indicate issues such as dehydration, renal problems, or inadequate fluid intake. Reporting this finding to the surgeon is crucial to ensure appropriate evaluation and intervention. Irrigating the catheter, applying manual pressure to the bladder, or increasing the IV flow rate are not appropriate actions based on the information provided and could potentially worsen the situation.

5. A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. Based on this finding, the nurse first:

• A. Calls the physician
• B. Increases the rate of the IV infusion
• C. Checks the client’s overall intake and output record
• D. Administers a 250-mL bolus of normal saline solution (0.9%)

Correct answer: C

Rationale: Clients are at risk of hypovolemia postoperatively, and decreased urine output can be an early sign. However, to accurately interpret this finding, the nurse must assess the overall fluid balance by checking the client’s intake and output records. Increasing the IV infusion rate or administering a bolus of normal saline solution without a physician's order would not be appropriate as these interventions require a prescription. The physician should be notified once the nurse has collected all necessary assessment data, including fluid status and vital signs.

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