Nursing Elites

1. A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?

• A. Clamp the chest tube
• B. Maintain the drainage below the level of the chest
• C. Elevate the chest tube above chest level
• D. Avoid frequent dressing changes

Correct answer: B

Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.

2. What are the complications of untreated fluid overload?

• A. Pulmonary edema and congestive heart failure
• B. Hypertension and electrolyte imbalance
• C. Liver failure and electrolyte imbalance
• D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

3. How should a healthcare professional assess a patient with chest pain?

• A. Assess the severity of pain and monitor ECG
• B. Administer nitroglycerin and provide oxygen
• C. Administer aspirin and provide pain relief
• D. Monitor for nausea and administer IV fluids

Correct answer: A

Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.

4. A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?

• A. Abdominal pain radiating to the right shoulder.
• B. Absent bowel sounds.
• C. Brown drainage on the surgical dressing.
• D. Urine output of 25 mL/hr.

Correct answer: D

Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.

5. How should a healthcare provider manage a patient with sepsis?

• A. Administer IV antibiotics
• B. Monitor vital signs
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: Managing a patient with sepsis requires a multi-faceted approach. Administering IV antibiotics is crucial to combat the underlying infection. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature helps assess the patient's response to treatment and identify any deterioration. Administering fluids is essential to maintain adequate blood pressure and organ perfusion. Therefore, all the options are integral components of sepsis management, making 'All of the above' the correct answer. Choices A, B, and C are all essential in the comprehensive care of a patient with sepsis. Omitting any of these aspects can lead to suboptimal outcomes, as each plays a critical role in addressing different aspects of sepsis management.

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