Nursing Elites

1. A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client as this is an expected finding.
• B. Add more water to the suction control chamber of the drainage system.
• C. Verify that the suction regulator is on and check the tubing for leaks.
• D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.

Correct answer: C

Rationale: In a three-chamber chest drainage system, the absence of bubbling in the suction control chamber indicates that no suction is being applied to the chest tube. The nurse should first verify that the suction regulator is on and check the tubing for any leaks that may be causing the lack of suction. Adding more water to the chamber or milking the chest tube are inappropriate actions and could potentially harm the client. Monitoring the client without taking action could lead to complications if the chest tube is not functioning properly.

2. A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?

• A. Increase protein intake.
• B. Limit fluid intake to 1500 mL/day.
• C. Consume a low-sodium diet.
• D. Take a daily multivitamin.

Correct answer: C

Rationale: For a client with cirrhosis experiencing ascites, the nurse should instruct them to consume a low-sodium diet. This dietary modification helps reduce fluid retention and manage ascites by decreasing the amount of sodium in the body, which helps prevent fluid accumulation in the abdomen. Limiting sodium intake is crucial in managing ascites and preventing further complications in clients with cirrhosis.

3. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

• A. Elevate the head of the client's bed.
• B. Measure and compare cuff pressures.
• C. Place the client on NPO status.
• D. Request a swallow study for the client.

Correct answer: B

Rationale: When food particles are noted during suctioning of a client with a tracheostomy tube, it can indicate tracheomalacia due to constant pressure from the tracheostomy cuff. This condition may lead to dilation of the tracheal passage. To address this issue, the nurse should measure and compare cuff pressures. By monitoring these pressures and comparing them to previous readings, the nurse can identify trends and potential complications. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not directly address the cuff pressure issue causing food particles in the secretions.

4. During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?

• A. Respiratory alkalosis
• B. Increased anteroposterior diameter of the chest
• C. Oxygen saturation level 96%
• D. Petechiae on chest

Correct answer: B

Rationale: COPD and emphysema are chronic respiratory conditions that can lead to changes in the shape of the chest. In clients with COPD, the anteroposterior diameter of the chest often increases, giving a barrel chest appearance. This change in chest shape is due to hyperinflation of the lungs and is a common physical finding in clients with COPD and emphysema. The other options are not typically associated with COPD and emphysema. Respiratory alkalosis is not a common finding in these clients. An oxygen saturation level of 96% is within the normal range and does not specifically relate to COPD. Petechiae on the chest are not typically associated with COPD or emphysema.

5. A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?

• A. Increase the wall suction.
• B. Strip the chest tube.
• C. Clamp the chest tube.
• D. Reposition the client.

Correct answer: D

Rationale: When a client with a chest tube connected to wall suction complains of chest burning, it may indicate that the tube is irritating or compressing nearby tissues. Repositioning the client can help relieve this irritation by ensuring the tube is not kinked or pulling on the tissues. Increasing suction, stripping the tube, or clamping it are not appropriate actions and could potentially worsen the situation or cause harm.

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