Nursing Elites

1. When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?

• A. Obtain a chest x-ray
• B. Apply sterile gauze to the insertion site
• C. Place tape around the insertion site
• D. Assess respiratory status

Correct answer: B

Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.

2. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?

• A. Use a professional interpreter service
• B. Nurse to interpret
• C. Provide translation services for a nominal fee to clients
• D. Evaluate the clients' understanding at regular intervals

Correct answer: B

Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.

3. A client is to receive thrombolytic therapy. Which of the following factors should be recognized as a contraindication to the therapy?

• A. Hip arthroplasty 2 weeks ago
• B. Elevated sedimentation rate
• C. Incident of exercise-induced asthma 1 week ago
• D. Elevated platelet count

Correct answer: A

Rationale: Thrombolytic therapy involves the use of medications to dissolve blood clots. Hip arthroplasty (joint replacement surgery) performed recently is a contraindication to thrombolytic therapy due to the risk of bleeding. Elevated sedimentation rate, exercise-induced asthma, and elevated platelet count are not contraindications to thrombolytic therapy.

4. The healthcare professional must verify the client’s identity before the administration of medication. Which of the following is the safest way to identify the client?

• A. Ask the client for their name
• B. Check the client’s identification band
• C. State the client’s name aloud and ask the client to repeat it
• D. Check the room number

Correct answer: B

Rationale: Verifying the client's identity before administering medication is crucial to ensure patient safety. Checking the client’s identification band is the safest and most reliable method to confirm the client's identity. Identification bands are specifically designed to prevent errors in patient identification and help healthcare professionals administer care to the correct individual. Asking the client for their name (Choice A) may lead to errors if the client is unable to communicate or if there is a language barrier. Stating the client’s name aloud and asking them to repeat it (Choice C) relies on the client's ability to respond accurately. Checking the room number (Choice D) does not directly confirm the client's identity and may lead to errors if multiple patients are in the same room.

5. When assessing a client with a history of asthma, which of the following factors should the nurse identify as a risk for asthma?

• A. Gender
• B. Environmental allergies
• C. Alcohol
• D. None of the above

Correct answer: B

Rationale: When assessing a client with a history of asthma, the nurse should identify environmental allergies as a risk factor for asthma. Environmental allergens such as pollen, dust mites, mold, and pet dander can trigger asthma symptoms and exacerbate the condition. Gender, alcohol consumption, and other factors may not directly contribute to the development or exacerbation of asthma.

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