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. What is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented?

• A. Administer acetaminophen
• B. Administer antibiotics
• C. Administer fluids
• D. Cool the patient with cold compresses

Correct answer: C

Rationale: Administering fluids is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented. Dehydration can worsen confusion and other symptoms in such a situation. Administering acetaminophen or cooling the patient with cold compresses may help reduce the fever but does not address the underlying issue. Administering antibiotics is not indicated for a high fever and disorientation without knowing the cause.

3. A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?

• A. PT 28 seconds
• B. INR 1.2
• C. aPTT 40 seconds
• D. Fibrinogen 350 mg/dL

Correct answer: B

Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.

4. A client who is at 10 weeks of gestation is being taught about nutrition during pregnancy. Which statement by the client indicates an understanding of the teaching?

• A. I should consume 1,200 calories per day.
• B. I should increase my daily intake of folic acid.
• C. I should drink 2 liters of water each day.
• D. I should limit my intake of iron-rich foods.

Correct answer: B

Rationale: The correct answer is B. Increasing folic acid intake is crucial during pregnancy to prevent neural tube defects. Option A is incorrect because calorie requirements during pregnancy vary and are generally higher than 1,200 calories per day. Option C is not specific to pregnancy nutrition teaching, although hydration is important. Option D is incorrect as iron-rich foods are typically recommended during pregnancy to prevent anemia.

5. A nurse is caring for a client who has a Clostridium difficile infection. Which of the following precautions should the nurse implement?

• A. Place the client in a negative pressure room
• B. Wear an N95 respirator mask when entering the room
• C. Wear a gown and gloves when providing care to the client
• D. Place a face mask on the client

Correct answer: C

Rationale: The correct precaution to implement when caring for a client with Clostridium difficile infection is to wear a gown and gloves when providing care. Clostridium difficile is primarily spread through contact with feces, so wearing personal protective equipment like gowns and gloves is crucial in preventing the spread of the infection. Placing the client in a negative pressure room (Choice A) is not necessary for Clostridium difficile. While wearing an N95 respirator mask (Choice B) is important for airborne precautions, it is not required for Clostridium difficile. Placing a face mask on the client (Choice D) is not a standard precaution for preventing the spread of Clostridium difficile.

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