Nursing Elites

1. A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

• A. Start a peripheral IV line to administer any necessary sedative drugs.
• B. Position the patient sitting upright on the edge of the bed and leaning forward.
• C. Obtain a collection device to hold a reasonable amount of pleural fluid for extraction.
• D. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

Correct answer: B

Rationale: The correct action for the nurse to take in preparing a patient for a thoracentesis is to position the patient sitting upright on the edge of the bed and leaning forward. This position helps fluid accumulate at the lung bases, making it easier to locate and remove. Sedation is not usually required for a thoracentesis, so starting an IV line for sedative drugs is unnecessary. Additionally, there are no restrictions on oral intake before the procedure since the patient is not sedated or unconscious. A large collection device to hold 2 to 3 liters of pleural fluid at one time is excessive as usually only 1000 to 1200 mL of pleural fluid is removed to avoid complications like hypotension, hypoxemia, or pulmonary edema. Therefore, the correct choice is to position the patient upright for the procedure.

2. When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?

• A. Weak cough effort
• B. Barrel-shaped chest
• C. Dry mucous membranes
• D. Bilateral crackles at lung bases

Correct answer: D

Rationale: Bilateral crackles at lung bases indicate a potential acute issue like heart failure. Immediate action is necessary in this situation. The nurse should conduct further assessments such as oxygen saturation and inform the healthcare provider promptly. A barrel-shaped chest and hyperresonance to percussion are typical signs of aging and do not require immediate action. A weak cough effort is common in older patients due to age-related changes, and dry mucous membranes are also expected in older individuals. While these findings may warrant further evaluation, they do not demand immediate action like bilateral crackles at lung bases.

3. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

• A. Dry palpebral and oral mucosa
• B. Crackles at bilateral lung bases
• C. Temperature 100.8?F (38.2?C)
• D. No bowel movement for 4 days

Correct answer: C

Rationale: The correct answer is the patient's temperature of 100.8�F (38.2�C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.

4. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

• A. Nutrition
• B. Elimination
• C. Activity
• D. Safety

Correct answer: D

Rationale: In caring for a client with severe depression, safety is a critical priority. The nurse must address precautions to prevent suicide as part of the care plan. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the immediate risk of harm associated with depression. Ensuring the client's safety by implementing measures to prevent self-harm or suicide is the priority intervention. Addressing nutrition, elimination, and activity can follow once the client's safety is assured.

5. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?

• A. Increase activity level.
• B. Maintain adequate nutrition
• C. Establish a stable environment
• D. Identify sources of hepatitis exposure

Correct answer: B

Rationale: The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.

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