Nursing Elites

1. A client with a chest tube attached to a closed drainage system has undergone a chest x-ray, which revealed that the affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:

• A. No fluctuation in the water seal chamber
• B. Continuous bubbling in the water seal chamber
• C. Increased drainage in the collection chamber
• D. Continuous gentle suction in the suction control chamber

Correct answer: A

Rationale: When the client's lung is fully reexpanded, the chest tube drainage system will no longer be actively draining, and there will be no fluctuation in the water seal chamber. Option B, continuous bubbling in the water seal chamber, indicates an air leak in the system, which is not expected when the lung is fully expanded. Option C, increased drainage in the collection chamber, would not be expected when the lung is reexpanded as there should be minimal to no drainage. Option D, continuous gentle suction in the suction control chamber, would not be appropriate when the lung is fully reexpanded and the chest tube is typically on a water seal system at this point to promote reexpansion and prevent air from entering the pleural space.

2. A nurse reviews a female client’s laboratory results. Which result from the client’s urinalysis should the nurse recognize as abnormal?

• A. pH 5.6
• B. Ketone bodies present
• C. Specific gravity of 1.020
• D. Clear and yellow color

Correct answer: B

Rationale: The correct answer is B: Ketone bodies present. Ketone bodies in urine indicate abnormal metabolism, specifically the incomplete breakdown of fatty acids. Normally, there should be no ketones present in urine. Ketone bodies are produced when the body uses fat sources instead of glucose for cellular energy. A pH range between 4.6 and 8, a specific gravity between 1.005 and 1.030, and clear yellow color in urine are considered normal findings for a female client’s urinalysis. Therefore, options A, C, and D are within normal ranges and not indicative of abnormal results in the urinalysis.

3. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?

• A. Decrease venous congestion.
• B. Maintain normal respirations.
• C. Maintain body temperature.
• D. Prevent injury to lower extremities.

Correct answer: A

Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.

4. A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.

• A. That informed consent is required
• B. That the test takes about 1 hour to complete
• C. That premedication for sedation may be necessary
• D. That food and fluids will be withheld before the procedure

Correct answer: B

Rationale: The correct answer is that the ERCP procedure takes about 1 hour to complete. Informed consent is required before the procedure. Premedication for sedation may be necessary as sedation is commonly used during ERCP to keep the client comfortable. Food and fluids are withheld before the procedure to prevent aspiration and ensure a clear view during the procedure. Position changes may be necessary to facilitate the passage of the tube.

5. After undergoing a renal biopsy, a client reports pain radiating to the front of the abdomen from the biopsy site. What finding should the nurse assess the client for?

• A. Bleeding
• B. Renal colic
• C. Infection at the site
• D. Increased temperature

Correct answer: A

Rationale: The correct answer is A: Bleeding. Pain radiating to the front of the abdomen from the renal biopsy site suggests bleeding, which should be promptly assessed and managed. Bleeding can lead to serious complications if not addressed timely. Renal colic (choice B) is associated with kidney stones and typically presents with severe flank pain. Infection at the site (choice C) would more likely present with localized signs such as redness, swelling, warmth, and tenderness. Increased temperature (choice D) alone is not specific to the issue described and may be indicative of various conditions.

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