Nursing Elites

1. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: Subcutaneous emphysema is the assessment finding that requires immediate intervention in a client with a chest tube following a pneumothorax. Subcutaneous emphysema can indicate a pneumothorax recurrence or air leak, which can compromise respiratory function and lead to serious complications. Oxygen saturation of 94% may be concerning but does not require immediate intervention as it is still within an acceptable range. Crepitus around the insertion site is common after chest tube placement and may not always indicate a problem. A blood pressure of 110/70 mmHg is within normal limits and does not require immediate intervention in this context.

2. A client with peptic ulcer disease is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?

• A. ‘I should avoid drinking alcohol to prevent irritation of my ulcer.’
• B. ‘I should take my antacids regularly, even if I don’t have symptoms.’
• C. ‘I should avoid eating spicy foods to prevent irritation of my ulcer.’
• D. ‘I should limit my caffeine intake to prevent irritation of my ulcer.’

Correct answer: B

Rationale: The statement ‘I should take my antacids regularly, even if I don’t have symptoms’ indicates a misunderstanding. Antacids should only be taken when symptoms are present to neutralize excess stomach acid. Taking antacids regularly when not experiencing symptoms may lead to metabolic alkalosis. Choices A, C, and D are correct statements for a client with peptic ulcer disease as they all focus on avoiding irritants that can exacerbate the condition.

3. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

• A. Urine output of 20 ml/hour
• B. Blood pressure of 138/88
• C. Respiratory rate of 18 breaths/min
• D. Temperature of 99.8°F

Correct answer: A

Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.

4. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L, and blood glucose is 310 mg/dl. Which action should the nurse implement?

• A. Infuse sodium chloride 0.9% (normal saline)
• B. Prepare an emergency dose of glucagon
• C. Determine the last time the client ate
• D. Check urine for ketone bodies with a dipstick

Correct answer: A

Rationale: In DKA, restoring fluid balance with sodium chloride is a priority to address the dehydration and electrolyte imbalances present in this condition. Choice B, preparing an emergency dose of glucagon, is incorrect because DKA is characterized by insulin deficiency, not glucagon deficiency. Choice C, determining the last time the client ate, is not the immediate priority in managing DKA. Choice D, checking urine for ketone bodies with a dipstick, may help confirm the diagnosis of DKA but is not the most critical intervention at this time.

5. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?

• A. Oxygen saturation of 95%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Drainage of 50 ml per hour

Correct answer: C

Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.

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