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 professional is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the healthcare professional include?

• A. Wear the brace over a T-shirt for 23 hours a day.
• B. Remove the brace while sleeping.
• C. Wear the brace directly against the skin.
• D. Remove the brace while eating.

Correct answer: A

Rationale: The correct answer is A. A Milwaukee brace should be worn over a T-shirt for 23 hours a day to reduce friction and chafing of the skin. This ensures that the brace is not directly against the skin, which can cause discomfort and skin irritation. Choice B is incorrect because the brace should typically be worn continuously, even while sleeping, unless otherwise instructed by a healthcare provider. Choice C is incorrect as wearing the brace directly against the skin can lead to skin issues. Choice D is incorrect since the brace should not be removed while eating to maintain the prescribed wear time.

3. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?

• A. I will increase my intake of vitamin C.
• B. I will avoid alcohol and tobacco.
• C. I will need to take folic acid supplements.
• D. I will avoid taking any medication without consulting my healthcare provider.

Correct answer: D

Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.

4. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?

• A. International normalized ratio (INR) of 1.0.
• B. Prothrombin time (PT) of 12 seconds.
• C. Partial thromboplastin time (PTT) of 60 seconds.
• D. International normalized ratio (INR) of 2.5.

Correct answer: D

Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.

5. A client with a history of heart failure is admitted with pulmonary edema. Which finding requires immediate intervention?

• A. Peripheral edema.
• B. Oxygen saturation of 88%.
• C. Jugular vein distention.
• D. Productive cough with pink, frothy sputum.

Correct answer: D

Rationale: A productive cough with pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. This finding requires immediate intervention to prevent respiratory compromise and worsening of the condition. Peripheral edema (Choice A) is a manifestation of heart failure but is not as urgent as addressing pulmonary edema. Oxygen saturation of 88% (Choice B) is low and requires attention, but the pink, frothy sputum signifies acute respiratory distress. Jugular vein distention (Choice C) can be seen in heart failure, but the immediate concern in this scenario is addressing the pulmonary edema to ensure adequate gas exchange and oxygenation.

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