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. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Yogurt, milk, and pudding
• B. Tea, lentils, and potato soup
• C. Ice cream, broth, and fruit smoothies
• D. Orange juice, mashed potatoes, and soft cheese

Correct answer: A

Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.

3. A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?

• A. Encourage the client to increase physical activity.
• B. Instruct the client to take rest breaks during walking.
• C. Apply warm compresses to the legs to improve circulation.
• D. Massage the affected leg to relieve the pain.

Correct answer: B

Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.

4. What is the first action the nurse should take when treating a 6-year-old child who stepped on a rusty nail?

• A. Cleanse the foot with soap and water
• B. Instruct the parent about tetanus boosters
• C. Apply a sterile dressing and refer for a tetanus booster
• D. Elevate the foot and wrap in a compression bandage

Correct answer: B

Rationale: The correct first action when a 6-year-old child steps on a rusty nail is to instruct the parent about tetanus boosters. This is important because stepping on a rusty nail increases the risk of tetanus infection. Choice A is incorrect as cleansing the foot comes after addressing the tetanus risk. Choice C is not the first action and should be done after addressing the immediate risk of tetanus. Choice D is not necessary as the priority is to prevent tetanus infection.

5. A client with heart failure is prescribed furosemide. The nurse notes that the client's potassium level is 3.1 mEq/L. What is the nurse's priority action?

• A. Administer a potassium supplement
• B. Encourage the client to eat potassium-rich foods
• C. Hold the next dose of furosemide
• D. Increase the client's fluid intake

Correct answer: A

Rationale: A potassium level of 3.1 mEq/L is considered low, indicating hypokalemia. Administering a potassium supplement is the nurse's priority action to prevent complications such as cardiac arrhythmias associated with low potassium levels. Encouraging the client to eat potassium-rich foods is beneficial in the long term but may not rapidly correct the low potassium level. Holding the next dose of furosemide may worsen the client's heart failure symptoms. Increasing the client's fluid intake is not the priority action in this situation; addressing the low potassium level takes precedence to prevent potential serious complications.

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