Nursing Elites

1. A healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, a serious condition that requires immediate attention. It can be a sign of an air leak in the lung or surrounding tissues. Constant bubbling in the suction control chamber is expected in a functioning chest tube system as it indicates proper suction. Intermittent bubbling in the water seal chamber is also normal, showing that the system is functioning correctly, allowing air to escape but not re-enter. Drainage of 50 ml per hour is within the expected range for chest tube output and does not require immediate intervention unless there are other concerning signs such as rapid increase or a sudden change in color or consistency.

2. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

3. After preparing and lubricating the enema set, what is the correct sequence of steps a nurse should follow when administering a large volume enema to a client?

• A. Administer the enema solution.
• B. Remove the enema tube from the client's rectum.
• C. Wrap the end of the enema tube with a disposable tissue.
• D. Insert the enema tube into the client's rectum.

Correct answer: B

Rationale: The correct sequence for administering a large volume enema is as follows: 1. Insert the enema tube into the rectum, 2. Administer the enema solution, 3. Clamp the tube, 4. Remove the tube, 5. Wrap the end with tissue. Therefore, the nurse should remove the enema tube from the client's rectum after administering the enema solution. Choices A, C, and D are incorrect because the enema tube should be removed from the rectum after the administration of the solution, not before or during the process.

4. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?

• A. Patients who appear unkempt may require guidance on hygiene practices.
• B. Personal preferences can be influenced by health conditions.
• C. The patient's illness may require teaching of new hygiene practices.
• D. Cultural perspectives on cleanliness can vary based on health status.

Correct answer: C

Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.

5. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
• B. The urine meter attached to the urinary drainage bag is completely full.
• C. There is a large dependent loop in the client's urinary drainage tubing.
• D. Purulent drainage is present around the insertion site of the feeding tube.

Correct answer: D

Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.

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