Nursing Elites

1. A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?

• A. Ensure the chest tube is clamped periodically
• B. Check for air leaks and ensure proper chest tube function
• C. Encourage deep breathing and coughing every 2 hours
• D. Ensure the client is positioned in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.

2. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

• A. Ignore the client's decision and proceed
• B. Report the situation to the provider
• C. Ask the family to convince the client
• D. Reassess the need for surgery with the client

Correct answer: B

Rationale: The correct action for the nurse to take is to report the client's decision to the provider who obtained informed consent. This ensures that the provider is informed of the client's change in decision and can discuss the situation further with the client. Choice A is incorrect as ignoring the client's decision is not appropriate and goes against the principles of patient autonomy. Choice C is incorrect because involving the family in convincing the client can be coercive and may not respect the client's autonomy. Choice D is incorrect because the nurse should not re-sign the informed consent form without the client's consent and a discussion with the provider.

3. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

4. Which nursing intervention is best for a client with constipation?

• A. Encourage the client to remain in bed to avoid straining
• B. Administer a stool softener as prescribed
• C. Increase fiber intake through dietary changes
• D. Encourage regular exercise to promote bowel movement

Correct answer: C

Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.

5. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

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