Nursing Elites

1. A client with a closed chest tube drainage system accidentally disconnects the chest tube while being turned by the nurse. What should the nurse do first?

• A. Submerge the end of the chest tube in a bottle of sterile water
• B. Clamp the chest tube with a Kelly clamp
• C. Call the health care provider
• D. Instruct the client to inhale and hold his breath

Correct answer: A

Rationale: When a chest tube becomes disconnected, the priority action is to immediately reattach it to the drainage system or submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. This helps prevent air from entering the pleural space and causing complications. Calling the health care provider is important but not the first action in this emergency. Instructing the client to inhale and hold his breath should be avoided as it can introduce atmospheric air into the pleural space, leading to potential issues. Clamping the chest tube is generally contraindicated, especially in cases of residual air leak or pneumothorax, as it may result in a tension pneumothorax by preventing air from escaping.

2. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

• A. Ask the nursing assistant to complete an incident report
• B. Check the client's level of consciousness and vital signs
• C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
• D. Ask the nursing assistant to assist in getting the client back to bed

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

3. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?

• A. Notify the physician.
• B. Clamp the chest tube.
• C. Replace the system.
• D. Document the finding

Correct answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

4. Which of the following is true of advanced directives?

• A. They should be appropriately documented in the client's chart.
• B. They are only applicable if the client has a terminal illness.
• C. They are required if the client is unconscious.
• D. They are non-legal requests.

Correct answer: A

Rationale: The correct answer is that advanced directives should be appropriately documented in the client's chart. Advanced directives are legal requests regarding a client's healthcare that come into effect under specific circumstances, regardless of the severity of their illness or level of consciousness. Choice B is incorrect because advanced directives can cover various healthcare decisions, not just terminal illnesses. Choice C is incorrect as advanced directives can be established and documented while the client is conscious, not only if they are unconscious. Choice D is incorrect because advanced directives are indeed legal requests, not non-legal requests.

5. The healthcare provider sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?

• A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinavir)
• B. two non-nucleoside reverse transcriptase inhibitors
• C. one protease inhibitor such as Nelfinavir
• D. two protease inhibitors

Correct answer: B

Rationale: In the scenario of a needle puncture requiring HIV prophylaxis, the CDC recommends initiating treatment with two non-nucleoside reverse transcriptase inhibitors, unless there is drug resistance. This regimen is preferred over other options such as a single protease inhibitor or two protease inhibitors due to its effectiveness and safety profile in this specific context. Non-nucleoside reverse transcriptase inhibitors are commonly used in post-exposure prophylaxis due to their activity against HIV and lower risk of resistance development compared to other antiretroviral drug classes.

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