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. What is an essential nursing intervention for a client experiencing delirium?

• A. Control behavioral symptoms with low-dose psychotropics
• B. Identify the underlying causative condition
• C. Increase environmental stimulation
• D. Administer antipsychotic medication

Correct answer: B

Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.

3. A healthcare professional is reviewing the medical record of a client who underwent surgery for a hip fracture. Which of the following findings should the healthcare professional report to the provider?

• A. Clear lung sounds
• B. Fever
• C. Pain in the operative leg
• D. Capillary refill of 2 seconds

Correct answer: B

Rationale: The correct answer is B: Fever. Fever in a postoperative client can indicate an infection, which is a serious complication and should be reported immediately to the provider for further evaluation and management. Clear lung sounds (Choice A) are a positive finding indicating normal respiratory function. Pain in the operative leg (Choice C) is expected postoperatively and should be managed with appropriate pain relief measures. Capillary refill of 2 seconds (Choice D) is within the normal range (less than 3 seconds) and is not a concerning finding postoperatively.

4. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

5. What are the differences between viral and bacterial infections?

• A. Viral infections often cause fatigue and body aches
• B. Bacterial infections often cause high fever and localized pain
• C. Viral infections are treated with antibiotics
• D. Bacterial infections are usually self-limiting

Correct answer: A

Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.

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