Nursing Elites

1. During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?

• A. Blood glucose - a common stress response.
• B. Intestinal peristalsis - should decrease due to stress.
• C. Peripheral blood vessels diameter - can vary in response to stress.
• D. Urine output - may vary but not a typical stress response.

Correct answer: A

Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.

2. The nurse is caring for a 17-month-old child with acetaminophen poisoning. Which laboratory reports should the nurse review first?

• A. Prothrombin time (PT) and partial thromboplastin time (PTT)
• B. Red blood cell and white blood cell counts
• C. Blood urea nitrogen and creatinine levels
• D. Liver enzymes (AST and ALT)

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the drug's metabolism in the liver. Monitoring liver enzymes such as AST and ALT is crucial as they indicate liver function and damage. Prothrombin time (PT) and partial thromboplastin time (PTT) (Choice A) are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts (Choice B) are not directly related to acetaminophen poisoning. Blood urea nitrogen and creatinine levels (Choice C) assess kidney function, but liver enzymes are more specific for evaluating liver damage in acetaminophen poisoning.

3. A healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, a serious condition that requires immediate attention. It can be a sign of an air leak in the lung or surrounding tissues. Constant bubbling in the suction control chamber is expected in a functioning chest tube system as it indicates proper suction. Intermittent bubbling in the water seal chamber is also normal, showing that the system is functioning correctly, allowing air to escape but not re-enter. Drainage of 50 ml per hour is within the expected range for chest tube output and does not require immediate intervention unless there are other concerning signs such as rapid increase or a sudden change in color or consistency.

4. A client has a closed wound drainage system. Which of the following actions should the nurse take?

• A. Avoid pressing the container down to create a vacuum
• B. Wear sterile gloves while handling the drainage system
• C. Reset the container with the drainage port closed
• D. Maintain the drain in a dependent position to facilitate drainage

Correct answer: D

Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.

5. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

• A. Use the complete name of the medication magnesium sulfate.
• B. Delete the space between the numerical dose and the unit of measure.
• C. Write the letter U when noting the dosage of insulin.
• D. Use the abbreviation SC when indicating an injection.

Correct answer: A

Rationale: The correct answer is to use the complete name of the medication magnesium sulfate. This is important to prevent confusion with morphine sulfate, which is abbreviated as MSO4. Choice B is incorrect as it is essential to maintain a space between the numerical dose and the unit of measure for clarity in medication documentation. Choice C is incorrect as the standard abbreviation for units is 'U' for international units, not for the dosage of insulin. Choice D is incorrect as the appropriate abbreviation for subcutaneous injection is 'SC,' not just 'SC.' Therefore, the nurse manager should emphasize using the full name of medications to avoid errors and ensure patient safety.

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