Nursing Elites

1. The healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, which requires immediate attention. The presence of crepitus suggests air leaking into the tissues, which could lead to respiratory compromise. Constant bubbling in the suction control chamber is expected and indicates proper functioning of the chest tube system. Intermittent bubbling in the water seal chamber is also normal, showing the system is intact. Drainage of 50 ml per hour is within the expected range for a chest tube.

2. A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

• A. The client is able to discuss the appropriate technique.
• B. The client is able to demonstrate the appropriate technique.
• C. The client states an understanding of the process.
• D. The client is able to write the steps on a piece of paper.

Correct answer: B

Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.

3. When moving a patient up in bed using a drawsheet with the help of another nurse, in which order will the nurses perform the steps, starting with the first one?

• A. Grasp the drawsheet firmly near the patient.
• B. Move the patient and drawsheet to the desired position.
• C. Position one nurse at each side of the bed.
• D. Place the drawsheet under the patient from shoulder to thigh.

Correct answer: C

Rationale: When moving a patient up in bed with a drawsheet and the assistance of another nurse, it is important to have one nurse positioned at each side of the bed initially. This allows for proper coordination and support during the patient movement. Placing the drawsheet under the patient from shoulder to thigh, grasping the drawsheet firmly near the patient, and moving the patient and drawsheet to the desired position follow after the nurses are positioned on each side of the bed. The correct sequence ensures a safe and coordinated approach to repositioning the patient in bed.

4. A client with a terminal illness is being educated by a healthcare provider about her decision to decline resuscitation in her living will. The client asks about the scenario of having difficulty breathing upon arrival at the emergency department.

• A. “We will apply oxygen through a tube in your nose.”
• B. “We will perform resuscitation efforts regardless of your wishes.”
• C. “You will receive only palliative care.”
• D. “We will ensure your comfort measures are met as per your advance directives.”

Correct answer: A

Rationale: Choice A is correct because applying oxygen through a tube in the nose provides comfort and aligns with the client's wishes for palliative care without resuscitation. This intervention can help alleviate breathing difficulties and maintain comfort without initiating full resuscitation efforts, respecting the client's decision. Choice B is incorrect as it goes against the client's expressed wish to decline resuscitation in her living will. Choice C is not the most appropriate response as it does not directly address the client's immediate concern of difficulty breathing and lacks specificity. Choice D, although focusing on comfort measures, is less specific than the correct choice A in addressing the client's immediate need for assistance with breathing.

5. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?

• A. 'I can see that this is upsetting you.'
• B. 'It is necessary for your treatment.'
• C. 'It will be over quickly, and you will feel better.'
• D. 'Let me explain again why this procedure is important.'

Correct answer: A

Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.

Similar Questions