Nursing Elites

1. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following actions should the nurse take?

• A. Clamp the chest tube when assisting the client out of bed.
• B. Empty the drainage system every 8 hours.
• C. Keep the collection device below the client's chest.
• D. Strip the chest tube every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.

2. A nurse is providing education to a client who is at 28 weeks gestation and has gestational diabetes mellitus. Which of the following statements should the nurse make?

• A. You will need to increase your protein intake during pregnancy.
• B. It is important to monitor your blood glucose levels closely.
• C. Gestational diabetes can increase the risk of developing type 2 diabetes later in life.
• D. You will need to avoid exercise while managing your blood sugar.

Correct answer: C

Rationale: The correct statement the nurse should make is that gestational diabetes can increase the risk of developing type 2 diabetes later in life. This information is crucial for the client's understanding of the potential long-term implications of gestational diabetes. Monitoring blood glucose levels closely (Choice B) is also important but does not address the long-term risk of developing type 2 diabetes. Choices A and D are incorrect as increasing protein intake during pregnancy and avoiding exercise are not recommended strategies for managing gestational diabetes.

3. A nurse is caring for a client who has a prescription for a high-protein diet. Which of the following foods should the nurse recommend?

• A. Almonds
• B. Cheddar cheese
• C. Chicken breast
• D. Pasta

Correct answer: C

Rationale: Chicken breast is an excellent choice for a high-protein diet as it is a lean source of protein. Almonds, while a good source of protein, also contain high amounts of fat. Cheddar cheese is high in protein but also high in saturated fat. Pasta is not a significant source of protein compared to chicken breast.

4. Which lab value is critical for monitoring warfarin therapy?

• A. Monitor INR
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.

5. A client has a nasogastric tube and is receiving intermittent enteral feedings. Which of the following actions should the nurse take to prevent aspiration?

• A. Administer a bolus feeding over 10 minutes.
• B. Elevate the head of the bed to 45 degrees during feedings.
• C. Flush the tube with 10 mL of sterile water before feedings.
• D. Position the client on the left side during feedings.

Correct answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

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