Nursing Elites

1. A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?

• A. Avoid using deodorant until the incision heals.
• B. Perform arm exercises 24 hours after surgery.
• C. Wear tight-fitting clothing to support the incision.
• D. Perform arm exercises 2 days after surgery.

Correct answer: A

Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.

2. A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?

• A. There is no fluctuation in the water seal chamber.
• B. There is continuous bubbling in the suction control chamber.
• C. There is tidaling in the water seal chamber.
• D. The drainage system is positioned at the level of the client's chest.

Correct answer: A

Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.

3. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of water after feeding
• B. Flush the tube with 10 mL of sterile water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

4. A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?

• A. You should wear a protective eye shield while sleeping.
• B. You should avoid bending over to pick things up.
• C. You should apply pressure to your eye if you feel pain.
• D. You should resume wearing your regular glasses immediately.

Correct answer: A

Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.

5. A nurse is assessing a client who has a new prescription for enoxaparin. Which of the following findings is a priority for the nurse to report?

• A. Platelet count of 200,000/mm³
• B. Hemoglobin level of 15 g/dL
• C. Respiratory rate of 22/min
• D. Dark, tarry stools

Correct answer: D

Rationale: The correct answer is D. Dark, tarry stools indicate gastrointestinal bleeding, which is a serious side effect of enoxaparin that requires immediate medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal ranges and are not directly related to the adverse effects of enoxaparin, so they do not take precedence over the urgent concern of gastrointestinal bleeding.

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