Nursing Elites

1. What is the priority when managing a client with a chest tube postoperatively?

• A. Clamp the chest tube for 30 minutes every 4 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.

2. How should a healthcare professional manage a patient with fluid overload?

• A. Restrict fluids and administer diuretics
• B. Increase fluid intake and provide oral diuretics
• C. Administer antibiotics and monitor weight
• D. Monitor weight and provide a low-sodium diet

Correct answer: A

Rationale: Corrected Question: When managing a patient with fluid overload, the appropriate approach involves restricting fluids and administering diuretics. This strategy helps remove excess fluid from the body and prevent complications associated with fluid overload. Choice B suggesting increasing fluid intake is incorrect as it would worsen the condition. Choice C, administering antibiotics, is unrelated to managing fluid overload. Choice D, monitoring weight and providing a low-sodium diet, is helpful but not as effective as fluid restriction and diuretics in managing fluid overload.

3. A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?

• A. Drink 1 liter of water per day.
• B. Take a laxative every morning.
• C. Increase your intake of refined grains.
• D. Walk for at least 30 minutes every day.

Correct answer: D

Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.

4. A client is postoperative following hip replacement surgery. Which of the following instructions should the nurse include in preventing dislocation of the prosthesis?

• A. Cross your legs at the knees
• B. Avoid bending your hip more than 90 degrees
• C. Sit with your legs elevated
• D. Avoid placing a pillow under your knees

Correct answer: B

Rationale: To prevent dislocation of the prosthesis after hip replacement surgery, it is essential to avoid bending the hip more than 90 degrees. This precaution helps maintain the stability of the hip joint and reduces the risk of prosthesis dislocation. Crossing legs at the knees (Choice A) can increase pressure on the hip joint, leading to instability. Sitting with legs elevated (Choice C) and avoiding placing a pillow under the knees (Choice D) do not directly address the risk of prosthesis dislocation.

5. A client is having difficulty voiding after removal of an indwelling urinary catheter. What should the nurse do?

• A. Assess for bladder distention after 6 hours
• B. Encourage the client to use a bedpan in the supine position
• C. Restrict the client's intake of oral fluids
• D. Pour warm water over the client's perineum

Correct answer: D

Rationale: The correct answer is to pour warm water over the client's perineum. This action helps stimulate voiding post-catheterization by promoting relaxation and providing sensory input. Assessing for bladder distention after 6 hours (Choice A) is important but not the immediate intervention needed for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not effectively address the issue of post-catheterization voiding difficulty. Restricting the client's intake of oral fluids (Choice C) is not appropriate and can lead to dehydration, which is not helpful in promoting voiding.

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