Nursing Elites

1. A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the healthcare provider. The healthcare provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to ask that the chest tube be removed. Which action should the nurse take first?

• A. Explain the procedure to the client, then remove the chest tube.
• B. Call the nursing supervisor.
• C. Inform the healthcare provider that removal of a chest tube is not a nursing procedure.
• D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube.

Correct answer: C

Rationale: The correct action for the nurse to take first is to inform the healthcare provider that removal of a chest tube is not a nursing procedure. Actual removal of a chest tube is the duty of a healthcare provider. If the healthcare provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies' policies and procedures may permit an advanced practice nurse to remove a chest tube, but there is no information in the question to indicate that the nurse is an advanced practice nurse. Choice A is incorrect because the nurse should not proceed with removing the chest tube without proper authorization. Choice B is incorrect as calling the nursing supervisor should come after clarifying with the healthcare provider. Choice D is incorrect as the nurse should not begin the process of removing the chest tube without proper guidance and authorization.

2. Which of the following foods might a client with hypercholesterolemia need to decrease intake of?

• A. broiled catfish
• B. hamburgers
• C. wheat bread
• D. fresh apples

Correct answer: B

Rationale: A client with hypercholesterolemia needs to decrease intake of foods that are high in cholesterol. Red meats like hamburgers are high in cholesterol, so their consumption should be reduced. Broiled catfish, wheat bread, and fresh apples are not high in cholesterol and do not need to be decreased in the client's diet. Therefore, the correct answer is hamburgers, as they are more likely to contribute to elevated cholesterol levels compared to the other options provided.

3. When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?

• A. Bathing a client who is confused and requires assistance with a shower
• B. Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
• C. Assisting a client requiring a bed bath and frequent ambulation with a cane
• D. Transporting a client who must be accompanied to physical therapy twice during the shift

Correct answer: B

Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.

4. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?

• A. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it
• B. Telling the nursing student to allow the client to rest
• C. Telling the client that the refusal of care will be informed to the health care provider
• D. Telling the nursing student to give the client the bath anyway

Correct answer: B

Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.

5. Which isolation procedure will be followed for secretions and blood?

• A. Respiratory Isolation
• B. Standard Precautions
• C. Contact Isolation
• D. Droplet Isolation

Correct answer: B

Rationale: The correct answer is Standard Precautions. Standard precautions are taken in all situations for all clients and involve all body secretions except sweat. They are designed to reduce the rate of transmission of microbes from one host to another or one source to another. Respiratory Isolation (Choice A) is used for diseases transmitted by airborne particles, not secretions and blood. Contact Isolation (Choice C) is for clients known or suspected to be infected with microorganisms that can be transmitted by direct or indirect contact. Droplet Isolation (Choice D) is used for diseases transmitted by large respiratory droplets expelled during coughing, sneezing, talking, or procedures.

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