Nursing Elites

1. The healthcare provider is caring for a client with a chest tube following thoracic surgery. Which intervention should the healthcare provider include in the plan of care?

• A. Clamp the chest tube for 30 minutes every 2 hours.
• B. Milk the chest tube to ensure patency.
• C. Keep the drainage system at the level of the chest.
• D. Ensure that the chest tube is not clamped or kinked.

Correct answer: D

Rationale: Ensuring that the chest tube is not clamped or kinked is essential to maintain proper drainage and prevent complications. Clamping the chest tube can lead to a buildup of pressure in the pleural space, causing potential harm to the client. Milking the chest tube is not recommended as it can cause damage to the delicate tubing. Keeping the drainage system at the level of the chest ensures proper drainage by gravity, preventing backflow of fluids, but ensuring the tube is not clamped or kinked takes precedence in this scenario.

2. The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?

• A. Oxygen saturation of 88%.
• B. Use of accessory muscles for breathing.
• C. Respiratory rate of 26 breaths per minute.
• D. Barrel-shaped chest.

Correct answer: C

Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.

3. The nurse is providing discharge teaching to a client with a new colostomy. Which statement by the client indicates a need for further teaching?

• A. I will avoid foods that cause gas.
• B. I will change my colostomy bag every week.
• C. I will use a skin barrier to protect the skin around the stoma.
• D. I will empty my colostomy bag when it is one-third full.

Correct answer: B

Rationale: The correct answer is B. Changing the colostomy bag every week is not sufficient; it should be changed more frequently to prevent leakage and skin irritation. Option A is correct as avoiding foods that cause gas can help manage colostomy-related symptoms. Option C is correct as using a skin barrier helps protect the skin around the stoma. Option D is correct as emptying the colostomy bag when it is one-third full helps prevent leakage and discomfort.

4. While screening all children in the third grade for head lice, the school nurse observes that one girl has a brownish thickening on her neck. Which action should the nurse take in response to this finding?

• A. review the child's medical folder for a list of allergies
• B. instruct the child's parents to begin treatment
• C. advise the child's parents to obtain a medical evaluation of the child
• D. none of the above

Correct answer: C

Rationale: The correct action for the nurse to take is to advise the child's parents to obtain a medical evaluation of the child. This is important because a medical professional needs to properly diagnose and treat the brownish thickening observed on the child's neck. Reviewing the child's medical folder for allergies (Choice A) is not appropriate in this situation as it does not address the specific concern. Instructing the child's parents to begin treatment (Choice B) without a proper diagnosis can be harmful and ineffective. Choosing 'none of the above' (Choice D) is not the best option when a potential health issue is identified; seeking a medical evaluation is the most appropriate course of action.

5. A community health nurse is working with a local organization to address food insecurity. Which action should the nurse prioritize?

• A. organizing a food drive to collect non-perishable items
• B. creating a community garden to grow fresh produce
• C. establishing a weekly meal program for those in need
• D. partnering with local businesses to donate food

Correct answer: C

Rationale: The correct answer is establishing a weekly meal program for those in need. This action prioritizes providing consistent and reliable access to food for individuals experiencing food insecurity. While organizing a food drive (Choice A) and partnering with local businesses to donate food (Choice D) are helpful, they may not offer a sustainable solution for ongoing food needs. Creating a community garden (Choice B) may promote self-sufficiency and access to fresh produce, but it may not address the immediate food needs of individuals who are food insecure. Therefore, establishing a weekly meal program is the most effective choice to ensure regular access to food for those in need.

Similar Questions