Nursing Elites

1. A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?

• A. Clamp the tube when the client is ambulating.
• B. Keep the collection device below the level of the client's chest.
• C. Carefully coil the tubes to prevent kinking.
• D. Position the client flat to avoid leaks in the tubing.

Correct answer: B

Rationale: Keeping the collection device below the level of the client's chest ensures proper drainage and prevents backflow of fluid into the patient's chest. This position allows gravity to assist in the drainage process. Clamping the tube when the client is ambulating can cause a buildup of pressure in the chest drainage system, potentially leading to complications. Carefully coiling the tubes is important to prevent obstructions and kinks that could impede the flow of drainage. Positioning the client flat may not be ideal as it could hinder proper drainage and increase the risk of leaks in the tubing.

2. While assessing a client with pulmonary tuberculosis, which of the following findings should the nurse expect?

• A. Lethargy
• B. High-grade fever
• C. Weight gain
• D. Dry cough

Correct answer: A

Rationale: When assessing a client with pulmonary tuberculosis, the nurse should expect lethargy as a common finding. Tuberculosis can cause fatigue and weakness due to the body's efforts to fight the infection. High-grade fever is another common symptom of tuberculosis, not weight gain or dry cough. Weight loss is more typical in tuberculosis due to decreased appetite and systemic effects of the infection. A persistent productive cough with sputum is more characteristic of tuberculosis rather than a dry cough.

3. When caring for an older adult client with a pulmonary infection, what action should the nurse take first?

• A. Encourage the client to increase fluid intake.
• B. Assess the client's level of consciousness.
• C. Raise the head of the bed to at least 45 degrees.
• D. Provide the client with humidified oxygen.

Correct answer: B

Rationale: Assessing the client's level of consciousness is the priority because it provides crucial information on the client's neurological status and response to the infection. Changes in consciousness can indicate deterioration or improvement in the client's condition, guiding further interventions and treatment.

4. A healthcare professional wishes to provide client-centered care in all interactions. Which action by the healthcare professional best demonstrates this concept?

• A. Assesses for cultural influences affecting healthcare
• B. Ensures that all the client's basic needs are met
• C. Informs the client and family about all upcoming tests
• D. Thoroughly orients the client and family to the room

Correct answer: A

Rationale: Client-centered care focuses on individualizing care to meet the client's unique needs, preferences, and values. Assessing for cultural influences affecting healthcare allows the healthcare professional to provide culturally sensitive and competent care, respecting the client's beliefs and practices. It promotes effective communication, understanding, and collaboration, essential components of client-centered care.

5. When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?

• A. A client who is scheduled for an abdominal x-ray and is awaiting transport
• B. A client who has a prescription for discharge
• C. A client who received oral pain medication 30 minutes ago
• D. A client who told an assistive personnel he is short of breath

Correct answer: D

Rationale: When a client expresses being short of breath, it may indicate a serious condition requiring immediate attention to ensure adequate oxygenation. This client should be seen first to assess the severity of the situation and initiate appropriate interventions. The other options, such as awaiting transport for an x-ray, having a prescription for discharge, or receiving oral pain medication 30 minutes ago, do not present immediate life-threatening concerns compared to a client experiencing shortness of breath.

Similar Questions