Nursing Elites

1. The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?

• A. The chest tube is securely taped at the insertion site.
• B. The water seal chamber is filled to the correct level.
• C. The chest drainage system is below chest level.
• D. There are no air leaks in the system.

Correct answer: C

Rationale: The correct answer is C. The chest drainage system should always be kept below chest level to ensure proper drainage. Having the system above chest level can result in ineffective drainage. Choices A, B, and D are all correct actions to maintain the integrity and functionality of the chest tube system. Securing the chest tube at the insertion site, maintaining the water seal chamber at the correct level, and ensuring there are no air leaks are all essential components of caring for a client with a chest tube post-surgery.

2. A client with schizophrenia is experiencing paranoia. What is the nurse's priority intervention?

• A. Reassure the client that their fears are unfounded.
• B. Place the client in a private room to reduce stimuli.
• C. Provide the client with a distraction to redirect their attention.
• D. Encourage the client to express their concerns and validate their feelings.

Correct answer: D

Rationale: Encouraging clients with paranoia to express their concerns and validating their feelings is crucial as it helps establish trust and reduce anxiety. This approach also aids in building a therapeutic relationship. Reassuring the client that their fears are unfounded (Choice A) may invalidate their feelings and worsen trust. Placing the client in a private room to reduce stimuli (Choice B) may be helpful in some situations but does not address the underlying issue of paranoia. Providing a distraction (Choice C) may temporarily shift the client's focus but does not address the root cause of the paranoia. Therefore, the priority intervention is to encourage the client to express their concerns and validate their feelings.

3. A client scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. Which intervention has the highest priority in preparing the client for the procedure?

• A. Provide detailed education about the procedure
• B. Administer prescribed anti-anxiety medication
• C. Instruct client to write down the questions
• D. Reassure the client about the safety of the procedure

Correct answer: C

Rationale: Encouraging the client to write down questions is the highest priority as it allows the nurse to address concerns systematically, reducing anxiety. This approach empowers the client and ensures that all concerns are covered before the procedure, reducing the risk of miscommunication or unaddressed fears. Providing detailed education about the procedure (choice A) is important but may not address the client's immediate anxiety. Administering anti-anxiety medication (choice B) should only be done if other interventions are ineffective or if prescribed by the healthcare provider. Reassuring the client about the safety of the procedure (choice D) is essential but may not address the specific questions and concerns causing anxiety.

4. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

5. A client with a urinary tract infection (UTI) is prescribed antibiotics. What is the most important instruction for the nurse to give the client?

• A. Take the antibiotics with food
• B. Complete the full course of antibiotics
• C. Increase fluid intake to at least 2 liters per day
• D. Take over-the-counter pain relievers for discomfort

Correct answer: B

Rationale: The most crucial instruction for the nurse to give a client with a UTI who is prescribed antibiotics is to complete the full course of antibiotics. Completing the full course of antibiotics is essential to ensure that the infection is fully treated and to prevent the development of antibiotic resistance. While taking antibiotics with food, increasing fluid intake, and managing discomfort with pain relievers are important aspects of UTI management, completing the prescribed course of antibiotics is the top priority to achieve the best treatment outcomes and prevent recurrence of the infection.

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