Nursing Elites

1. A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the past 24 hours.
• B. Intermittent bubbling in the water seal chamber.
• C. Continuous bubbling in the water seal chamber.
• D. Tidaling in the water seal chamber.

Correct answer: C

Rationale: Continuous bubbling in the water seal chamber should be reported to the provider as it can indicate an air leak. This finding suggests that air is escaping from the pleural space, which can lead to lung collapse or pneumothorax. Drainage of 75 mL in the past 24 hours is within the expected range for a client with a chest tube and is not a cause for concern. Intermittent bubbling in the water seal chamber is a normal finding that indicates the system is functioning properly. Tidaling in the water seal chamber is also an expected finding that shows the fluctuation of fluid with the client's breathing and is not alarming.

2. A client has had vomiting and diarrhea for the past 3 days. Which of the following findings indicates the client is experiencing fluid volume deficit?

• A. Jugular vein distention
• B. Bradycardia
• C. Increased respiratory rate
• D. Bounding pulses

Correct answer: C

Rationale: An increased respiratory rate is a sign of fluid volume deficit as the body attempts to compensate for decreased blood volume. Jugular vein distention, bradycardia, and bounding pulses are not typical findings of fluid volume deficit. Jugular vein distention is more commonly associated with fluid volume overload, bradycardia can be a sign of fluid volume excess or other issues, and bounding pulses are not typically seen in fluid volume deficit.

3. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

4. How should a healthcare provider manage a patient with chronic kidney disease?

• A. Limit fluid intake
• B. Increase potassium intake
• C. Provide a high-protein diet
• D. Administer IV antibiotics

Correct answer: A

Rationale: Limiting fluid intake is essential in managing patients with chronic kidney disease to prevent fluid overload, which can worsen kidney function. Increasing potassium intake is not recommended as patients with kidney disease often need to limit potassium. Providing a high-protein diet may put extra strain on the kidneys, so it is not ideal. Administering IV antibiotics is not a standard treatment for chronic kidney disease.

5. A nurse is caring for a client following the application of a cast. Which of the following actions should the nurse take first?

• A. Place an ice pack over the cast
• B. Palpate the pulse distal to the cast
• C. Teach the client to keep the cast clean and dry
• D. Position the casted extremity on a pillow

Correct answer: B

Rationale: Palpating the pulse distal to the cast is the priority as it assesses for circulation. Ensuring adequate blood flow is essential to prevent complications such as compartment syndrome. Placing an ice pack over the cast could cause constriction of blood vessels, further compromising circulation. Teaching the client about cast care and positioning the casted extremity on a pillow are important but do not take precedence over assessing circulation.

Similar Questions