Nursing Elites

1. The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?

• A. Intermittent bubbling in the water seal chamber.
• B. Drainage of 75 ml in the first hour post-insertion.
• C. Crepitus around the insertion site.
• D. Fluctuation of the water level in the water seal chamber with respiration.

Correct answer: C

Rationale: Crepitus (subcutaneous emphysema) around the insertion site can indicate air leakage, requiring immediate intervention to prevent complications such as pneumothorax. This assessment finding suggests that there may be a break in the chest tube system, leading to air entering the pleural space. Prompt intervention is crucial to prevent respiratory compromise and further complications.

2. The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?

• A. Check the client's vital signs before starting the transfusion.
• B. Verify the client's identity and blood compatibility.
• C. Administer the blood with normal saline.
• D. Monitor the client for the first 15 minutes of the transfusion.

Correct answer: B

Rationale: Verifying the client's identity and blood compatibility is the most critical step in ensuring client safety during a blood transfusion. This process helps prevent transfusion reactions by confirming that the correct blood product is being administered to the right patient.

3. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

• A. Explain that distrust is related to feeling anxious.
• B. Initiate short, frequent contacts with the client.
• C. Explain that these beliefs are related to her illness.
• D. Offer to keep the belongings at the nurse's desk.

Correct answer: B

Rationale: Initiating short, frequent contacts with the client is the most appropriate action to promote trust. This approach helps build trust and rapport, addressing the client's need for security. By maintaining regular contact, the nurse can provide reassurance and support, which can help alleviate the client's anxiety related to her delusional beliefs. Choice A does not directly address the client's need for trust and security. Choice C focuses on the client's illness but does not actively address building trust. Choice D, offering to keep the belongings at the nurse's desk, may not be well-received by the client and could potentially worsen her anxiety and distrust.

4. A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?

• A. Notify the healthcare provider of the assessment findings.
• B. Determine if the client received anesthesia during delivery.
• C. Assign a licensed nurse to reassess the client's vital signs.
• D. Obtain a STAT hemoglobin and hematocrit.

Correct answer: B

Rationale: The correct action to implement first is to determine if the client received anesthesia during delivery. Anesthesia can be a potential cause of postpartum headaches. This information is crucial in assessing and managing the client's condition effectively before considering other interventions. It helps in identifying possible contributing factors to the client's complaint of a severe headache and guides the healthcare team in providing appropriate care and treatment.

5. A patient with type 1 diabetes is prescribed insulin glargine. What is the primary characteristic of this insulin?

• A. Rapid-acting
• B. Intermediate-acting
• C. Long-acting
• D. Short-acting

Correct answer: C

Rationale: Insulin glargine is classified as a long-acting insulin. It is designed to provide a consistent level of insulin over approximately 24 hours, helping to keep blood glucose levels stable throughout the day. This long duration of action makes it suitable for basal insulin replacement in patients with type 1 diabetes, providing a background level of insulin to mimic the body's natural release of insulin between meals and overnight.

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