Nursing Elites

1. A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?

• A. Clamp the chest tube intermittently.
• B. Keep the drainage system below chest level.
• C. Empty the drainage chamber every 4 hours.
• D. Apply sterile gauze around the insertion site daily.

Correct answer: B

Rationale: To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.

2. A healthcare professional is planning a community education program about colorectal cancer. Which of the following risk factors should the professional identify as modifiable?

• A. Family history
• B. Smoking
• C. Age
• D. Gender

Correct answer: B

Rationale: The correct answer is B: Smoking. Smoking is a modifiable risk factor for colorectal cancer. It is within an individual's control to quit smoking, thereby reducing their risk of developing colorectal cancer. Choices A, C, and D are non-modifiable risk factors. Family history, age, and gender are factors that individuals cannot change or control. While family history can influence risk, it is not something that can be modified. Age and gender are also non-modifiable factors when it comes to colorectal cancer risk.

3. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

• A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
• B. Administer oxygen to a client who has an oxygen saturation of 91%
• C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
• D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: When using the ABC approach to client care, the nurse should identify that the priority intervention is administering oxygen. In this scenario, the client's oxygen saturation is only 91%, which is below the normal range of 95% and above. Oxygen is essential for adequate tissue perfusion and oxygenation of vital organs. Administering oxygen takes precedence over other interventions to ensure the client's physiological needs are met first. Choice A can be addressed after ensuring adequate oxygenation. Choice C is important for preventing postoperative complications but is not as urgent as addressing oxygen saturation. Choice D is a common postoperative intervention, but in this case, ensuring adequate oxygenation is the priority over IV fluid administration.

4. A nurse is teaching a client with newly diagnosed hypertension about lifestyle changes. Which of the following recommendations should the nurse make?

• A. Limit sodium intake to 3,000 mg per day.
• B. Exercise for at least 30 minutes most days of the week.
• C. Drink no more than two alcoholic drinks per day.
• D. Increase fluid intake to at least 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: 'Exercise for at least 30 minutes most days of the week.' Regular exercise, especially aerobic activity, is known to help lower blood pressure and should be included in lifestyle changes for managing hypertension. Choice A is incorrect because the recommended sodium intake for individuals with hypertension is usually lower than 3,000 mg per day. Choice C is incorrect as it is advisable to limit alcohol intake to one drink per day for women and two drinks per day for men. Choice D is incorrect because increasing fluid intake to 3 liters per day may not be necessary and could be harmful in some cases, depending on the individual's health status.

5. A 65-year-old client is taking methylprednisolone. What pharmacological action should the nurse expect with this therapy?

• A. Suppression of beta2 receptors.
• B. Suppression of airway mucus production.
• C. Fortification of bones.
• D. Suppression of candidiasis.

Correct answer: B

Rationale: The correct answer is B: 'Suppression of airway mucus production.' Methylprednisolone, a corticosteroid, is known to suppress airway mucus production. While corticosteroids can enhance the responsiveness of beta2 receptors, they are not directly involved in the suppression of these receptors (Choice A). Corticosteroids can lead to adverse effects such as bone loss, rather than fortification of bones (Choice C). They can also increase the risk of infections like candidiasis but do not directly suppress it (Choice D). Therefore, the most expected pharmacological action of methylprednisolone therapy is the suppression of airway mucus production.

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