Nursing Elites

1. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?

• A. Clamp the tube if there is excessive drainage
• B. Empty the drainage chamber every 2 hours
• C. Keep the drainage system below chest level
• D. Milk the tube to prevent clots from forming

Correct answer: C

Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.

2. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action in this situation. Standing to void often helps relieve the bladder, especially after surgery. Option A, having him drink several glasses of water, may not be as effective as the client might already be adequately hydrated. Option B, Crede maneuver, is a technique for emptying the bladder by applying manual pressure and is not the first-line intervention for a client who cannot void post-surgery. Option D, waiting 2 hours before trying to void again, may delay necessary intervention if the client is experiencing urinary retention.

3. The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?

• A. Short half-life
• B. High therapeutic index
• C. Highly protein-bound
• D. Low bioavailability

Correct answer: C

Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.

4. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?

• A. Assess for signs of infection.
• B. Monitor the client’s fluid intake and output.
• C. Check the client’s capillary blood glucose level.
• D. Assess the client’s serum potassium level.

Correct answer: C

Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.

5. A client with a recent myocardial infarction is prescribed a beta-blocker. What side effect should the nurse monitor for?

• A. Monitor the client for bradycardia.
• B. Check the client’s blood pressure for signs of hypotension.
• C. Monitor the client for signs of hyperglycemia.
• D. Monitor for signs of fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Check the client’s blood pressure for signs of hypotension.' Beta-blockers can lead to decreased heart rate, but bradycardia is not the primary side effect to monitor. Monitoring for bradycardia is more relevant when administering medications like digoxin. Hyperglycemia is associated with medications like corticosteroids, not beta-blockers. Fluid retention is a side effect seen with medications like corticosteroids or calcium channel blockers, not beta-blockers. Therefore, in a client taking a beta-blocker after a myocardial infarction, monitoring for hypotension is crucial due to the medication's mechanism of action.

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