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. A client who is at 38 weeks of gestation and has a history of hepatitis C asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?

• A. You may breastfeed unless your nipples are cracked or bleeding.
• B. You must use a breast pump to provide breast milk.
• C. You must use a nipple shield when breastfeeding.
• D. You may breastfeed after your baby develops antibodies.

Correct answer: A

Rationale: The correct response is A: 'You may breastfeed unless your nipples are cracked or bleeding.' In the case of hepatitis C, breastfeeding is generally safe unless the mother's nipples are cracked or bleeding, which could increase the risk of transmission to the baby. Choice B is incorrect as using a breast pump is not a mandatory requirement for breastfeeding with hepatitis C. Choice C is incorrect as a nipple shield is not necessary in this situation. Choice D is incorrect because the baby developing antibodies does not impact the decision to breastfeed in the context of hepatitis C.

3. A nurse is caring for a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Tachycardia
• C. Hypotension
• D. Diaphoresis

Correct answer: A

Rationale: Corrected Rationale: Bradycardia is a common sign of hypoglycemia due to the body's response to low blood sugar. During hypoglycemia, the body releases epinephrine, leading to sympathetic nervous system activation. This can result in bradycardia as a compensatory mechanism to preserve glucose for vital organs such as the brain. Tachycardia, hypotension, and diaphoresis are more commonly associated with hypoglycemia when it progresses to severe stages and the body's compensatory mechanisms are overwhelmed.

4. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

5. What are the signs of opioid withdrawal, and how should it be managed?

• A. Sweating, nausea; administer methadone
• B. Muscle cramps, vomiting; administer naloxone
• C. Tremors, sweating; administer buprenorphine
• D. Fever, agitation; provide sedatives

Correct answer: A

Rationale: The signs of opioid withdrawal typically include sweating and nausea. The correct management approach involves administering methadone to alleviate the symptoms. Choice B is incorrect because naloxone is used to reverse opioid overdose, not for managing withdrawal symptoms. Choice C is incorrect as buprenorphine is typically used to treat opioid addiction, not just withdrawal symptoms. Choice D is incorrect as sedatives are not the primary treatment for opioid withdrawal.

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