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 nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?

• A. Restrict the client's fluid intake.
• B. Monitor the client's deep-tendon reflexes.
• C. Place the client in the lithotomy position.
• D. Encourage the client to ambulate frequently.

Correct answer: B

Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.

3. How should a healthcare provider respond to a patient with a suspected pulmonary embolism?

• A. Administer oxygen and call for emergency assistance
• B. Position the patient in a prone position and give fluids
• C. Administer anticoagulants and elevate the patient's legs
• D. Administer thrombolytics and perform chest physiotherapy

Correct answer: A

Rationale: Administering oxygen and calling for emergency assistance are the immediate priorities when managing a suspected pulmonary embolism. Oxygen helps support the patient's respiratory function, while emergency assistance is crucial for further evaluation and treatment. Positioning the patient in a prone position or giving fluids can worsen the condition by impeding blood flow. Administering anticoagulants may be part of the treatment plan but is not the initial response. Thrombolytics and chest physiotherapy are not first-line treatments for suspected pulmonary embolism and can even be harmful without prior evaluation.

4. What are the signs and symptoms of a pulmonary embolism?

• A. Sudden shortness of breath
• B. Chest pain
• C. Cough with blood
• D. All of the above

Correct answer: D

Rationale: A pulmonary embolism can manifest with sudden shortness of breath, chest pain, and coughing up blood. These symptoms are classic presentations of a pulmonary embolism due to the blockage of blood flow to the lungs. Therefore, the correct answer is 'All of the above.' Each symptom alone can be seen in various other conditions, but when occurring together, they strongly suggest a pulmonary embolism. Sudden shortness of breath is due to decreased oxygenation, chest pain can result from the strain on the heart, and coughing with blood may indicate damage to the lung tissue. Choosing any single symptom would not encompass the full range of presentations seen in a pulmonary embolism.

5. A healthcare professional is preparing to discharge a client who is immunocompromised. Which of the following vaccines should the professional plan to administer?

• A. Varicella
• B. Influenza
• C. Hepatitis B
• D. Pneumococcal polysaccharide

Correct answer: D

Rationale: Immunocompromised clients have weakened immune systems, making them more susceptible to infections. The pneumococcal polysaccharide vaccine is recommended for these individuals to help prevent pneumococcal infections, which can be severe and life-threatening. Varicella, Influenza, and Hepatitis B vaccines are not specifically indicated for immunocompromised clients. Varicella contains a live virus that can cause infections in immunocompromised individuals. Influenza is generally recommended for all individuals over 6 months of age but does not have the same priority as the pneumococcal vaccine for immunocompromised clients. Hepatitis B vaccine is crucial for preventing Hepatitis B infection but is not directly related to the increased infection risk faced by immunocompromised clients.

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