Nursing Elites

1. When caring for a client with a chest tube, which intervention is most important to include in the plan of care?

• A. Maintain continuous suction on the chest tube.
• B. Clamp the chest tube during client movement.
• C. Ensure that the chest tube is clamped for at least 8 hours each day.
• D. Keep the collection chamber below the level of the chest.

Correct answer: D

Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.

2. The healthcare provider is conducting a health assessment for a family in a rural area. Which intervention should the healthcare provider prioritize to address the family's health needs?

• A. Providing information on local healthcare resources
• B. Teaching the family about proper nutrition
• C. Assisting the family in scheduling medical appointments
• D. Connecting the family with transportation services

Correct answer: A

Rationale: In rural areas, access to healthcare may be limited. Providing information on local healthcare resources is essential to ensure the family can access necessary services. While proper nutrition (choice B) and medical appointments (choice C) are important, having access to healthcare resources is fundamental. Transportation services (choice D) may be helpful but addressing the availability of healthcare resources should be the priority.

3. When visiting a community health clinic, a client's blood pressure is measured at 146/94. What information should the nurse provide the client?

• A. Participate in an exercise program for 6 weeks
• B. Obtain blood pressure daily for 2 weeks
• C. Increase dietary intake of omega-3 fatty acids
• D. Begin a low sodium diet immediately

Correct answer: D

Rationale: The correct answer is to advise the client to begin a low sodium diet immediately. High sodium intake can contribute to elevated blood pressure levels. By reducing sodium intake, blood pressure can be effectively lowered. Option A, participating in an exercise program, is beneficial for overall health but may not provide immediate impact on blood pressure. Option B, obtaining blood pressure daily for 2 weeks, may not address the underlying cause or provide immediate intervention. Option C, increasing dietary intake of omega-3 fatty acids, though beneficial for heart health, may not have an immediate impact on lowering blood pressure compared to reducing sodium intake.

4. During a home visit, the nurse observes that an elderly client has numerous bruises on her arms and appears fearful of her caregiver. What should the nurse do first?

• A. report the findings to adult protective services
• B. ask the client how she got the bruises
• C. document the observations in the client's medical record
• D. discuss the observations with the caregiver

Correct answer: B

Rationale: The initial step for the nurse should be to ask the client how she got the bruises. This approach allows the nurse to directly assess the situation, gather information from the client, and potentially uncover signs of abuse. Reporting to adult protective services should come after obtaining more details from the client to ensure appropriate action. Documenting the observations is important but should follow gathering information from the client. Discussing the observations with the caregiver may not be appropriate as the caregiver could be the source of abuse, and involving them first may jeopardize the client's safety.

5. A client with type 2 diabetes mellitus is admitted with hyperosmolar hyperglycemic state (HHS). Which laboratory result requires immediate intervention?

• A. Serum osmolality of 320 mOsm/kg.
• B. Serum glucose of 600 mg/dL.
• C. Serum potassium of 4.5 mEq/L.
• D. Serum sodium of 140 mEq/L.

Correct answer: B

Rationale: A serum glucose level of 600 mg/dL is extremely high in a client with hyperosmolar hyperglycemic state (HHS) and poses a significant risk of serious complications such as dehydration, coma, and electrolyte imbalances. Rapid intervention is crucial to normalize the glucose level and prevent further deterioration. Serum osmolality of 320 mOsm/kg, serum potassium of 4.5 mEq/L, and serum sodium of 140 mEq/L, while important to monitor in HHS, do not represent an immediate life-threatening condition that requires urgent intervention compared to the critically high glucose level.

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