Nursing Elites

1. What is the priority for the nurse when caring for a patient with a chest tube?

• A. Ensure tube patency and observe for air leaks
• B. Maintain sterile technique during dressing changes
• C. Monitor drainage and record output
• D. Observe for signs of infection and monitor for subcutaneous emphysema

Correct answer: A

Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.

2. A client is to start taking furosemide and is being taught about dietary modifications by a nurse. Which of the following foods should the nurse recommend to the client?

• A. Cabbage
• B. Bananas
• C. Carrots
• D. Potatoes

Correct answer: B

Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which helps counter the potassium-depleting effects of furosemide. Furosemide is a loop diuretic that can lead to potassium loss, so including potassium-rich foods like bananas in the diet can help maintain a healthy potassium level. Choices A, C, and D do not specifically address the potassium needs associated with furosemide therapy and are not the most appropriate recommendations in this context.

3. What should be included in dietary teaching for a client with chronic kidney disease?

• A. Increase potassium-rich foods in the diet
• B. Limit potassium and phosphorus intake
• C. Increase intake of protein-rich foods
• D. Increase fluid intake to prevent dehydration

Correct answer: B

Rationale: The correct answer is to limit potassium and phosphorus intake for a client with chronic kidney disease. Excessive potassium and phosphorus can be harmful to individuals with compromised kidney function. Option A is incorrect because increasing potassium-rich foods can exacerbate hyperkalemia in individuals with kidney disease. Option C may not be ideal as excessive protein intake can put extra strain on the kidneys. Option D is not the priority; while adequate fluid intake is important, it is not the primary focus when teaching dietary considerations for chronic kidney disease.

4. A nurse is caring for a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the first hour after surgery.
• B. Constant bubbling in the water seal chamber.
• C. Tidaling in the water seal chamber.
• D. Client report of pain at the chest tube insertion site.

Correct answer: B

Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.

5. A nurse is reviewing the plan of care for a client who is undergoing total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Monitor the client's electrolyte levels daily
• B. Weigh the client daily
• C. Monitor the client's blood glucose levels every 6 hours
• D. Change the TPN tubing every 24 hours

Correct answer: D

Rationale: The correct intervention for the nurse to include in the plan of care for a client undergoing total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. Changing the tubing at regular intervals helps reduce the risk of infection associated with central venous catheters. Monitoring electrolyte levels daily (Choice A) is important but not specific to TPN. Weighing the client daily (Choice B) is important for monitoring fluid status but not directly related to TPN. Monitoring blood glucose levels every 6 hours (Choice C) is essential for clients receiving TPN, but changing the tubing is a more critical intervention to prevent infections.

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