Nursing Elites

1. A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?

• A. Do nothing; this is a normal response
• B. Strip the tubing to remove any clots
• C. Place a clamp on the tube near the client's chest
• D. Remove the collection chamber and connect the tubing to a new device

Correct answer: C

Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately. Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak. Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action. Choice D is incorrect as it does not address the immediate need to locate and address the leak.

2. Which of the following screening tools have been found to have high diagnostic accuracy for screening for intimate partner violence?

• A. Hurt, Insult, Threaten, and Scream (HITS)
• B. Humiliation, Afraid, Rape, and Kick (HARK)
• C. Slapped, Threatened, and Thrown (STaT)
• D. All of the above

Correct answer: D

Rationale: All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.

3. Which of the following components is associated with hypertonic dehydration?

• A. Plasma sodium levels above 150 mEq/L
• B. Fluid moves from extracellular space to intracellular space
• C. Water loss is greater than electrolyte loss
• D. Physical signs and symptoms are grossly apparent

Correct answer: C

Rationale: The correct answer is 'Water loss is greater than electrolyte loss.' In hypertonic dehydration, there is a higher loss of water compared to electrolytes, leading to elevated concentrations of electrolytes in the body. This condition is characterized by plasma sodium levels above 150 mEq/L. As water moves from the extracellular space to the intracellular space, it results in cellular dehydration. Choice A is incorrect because the plasma sodium levels associated with hypertonic dehydration are typically above 150 mEq/L, not between 130 and 150 mEq/L. Choice B is incorrect as fluid moves from the extracellular space to the intracellular space in hypertonic dehydration. Choice D is incorrect because physical signs and symptoms may not always be grossly apparent in hypertonic dehydration.

4. Which of the following is a local sign of infection?

• A. Swelling
• B. Rapid pulse
• C. Fever
• D. High white blood count

Correct answer: A

Rationale: A local sign of infection refers to symptoms that are specific to the area of infection. Swelling, heat, pain, and redness near the infected site are examples of local signs. In the context of infection, swelling occurs due to an accumulation of fluid and immune cells at the site of infection. Rapid pulse, fever, and high white blood count are more systemic responses to infection and not specific local signs. Rapid pulse can indicate systemic distress or sepsis, fever is a systemic response to infection, and high white blood count is a laboratory finding that suggests an immune response but is not a direct sign of infection at a specific site.

5. Which of the following white blood cells is the smallest and can be involved in humoral immunity?

• A. Lymphocyte
• B. Monocyte
• C. Basophil
• D. Erythrocyte

Correct answer: A

Rationale: The correct answer is 'Lymphocyte.' Lymphocytes are the smallest type of white blood cells and play a crucial role in humoral immunity by producing antibodies. Monocytes are actually the largest white blood cells and are involved in phagocytosis rather than humoral immunity. Basophils are a type of granulocyte involved in allergic reactions, and erythrocytes are red blood cells responsible for oxygen transport, not part of the immune system.

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