Nursing Elites

1. Which of the following is a critical nursing action when managing a patient with a chest tube?

• A. Keep the chest tube clamped at all times.
• B. Ensure the chest tube is connected to a closed drainage system.
• C. Empty the chest tube drainage system every 2 hours.
• D. Disconnect the chest tube when the patient is ambulating.

Correct answer: B

Rationale: The correct answer is B: "Ensure the chest tube is connected to a closed drainage system." This is a critical nursing action when managing a patient with a chest tube because it is essential for proper drainage and to prevent complications such as air leaks or infections. Option A is incorrect because keeping the chest tube clamped at all times would prevent proper drainage and could lead to complications. Option C is incorrect as emptying the chest tube drainage system should be done based on assessment findings rather than a fixed time interval. Option D is incorrect because disconnecting the chest tube when the patient is ambulating can lead to complications like a pneumothorax.

2. A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

• A. Deficits in the right visual field
• B. Unable to discriminate words and letters
• C. Motor retardation
• D. Poor impulse control

Correct answer: D

Rationale: The correct answer is D, poor impulse control. Right hemisphere strokes commonly affect judgment and safety awareness, leading to poor impulse control. Choices A, B, and C are incorrect for this scenario. Deficits in the right visual field are associated with left hemisphere strokes, while the inability to discriminate words and letters is typically seen with left hemisphere damage. Motor retardation is more common in strokes affecting the motor areas of the brain, not specifically related to right hemisphere strokes.

3. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

4. A home health nurse is teaching about chest physiotherapy (CPT) treatments to a client with COPD. Which of the following client statements should the nurse identify as an indication that the teaching has been understood?

• A. My coughing will decrease during CPT treatments.
• B. CPT treatments will decrease my respiratory infections.
• C. I will perform postural drainage after eating meals.
• D. CPT treatments will help cure my COPD.

Correct answer: B

Rationale: The correct answer is B because chest physiotherapy (CPT) helps reduce respiratory infections by loosening mucus in the lungs. Choice A is incorrect because coughing may temporarily increase during CPT treatments as mucus is being cleared. Choice C is incorrect because postural drainage is typically performed before meals. Choice D is incorrect because while CPT can help manage symptoms and improve lung function in COPD, it does not cure the disease.

5. How should a healthcare provider respond when a patient expresses concerns about the side effects of a prescribed medication?

• A. Reassure the patient that side effects are rare.
• B. Discuss the benefits and risks of the medication with the patient.
• C. Encourage the patient to speak to the pharmacist.
• D. Refer the patient to another healthcare provider for information.

Correct answer: B

Rationale: When a patient expresses concerns about medication side effects, it is crucial for the healthcare provider to discuss the benefits and risks of the medication with the patient. This approach helps the patient make an informed decision about their treatment. Choice A is incorrect because dismissing the patient's concerns by reassuring them that side effects are rare may not address the patient's specific worries. Choice C, while pharmacists can provide valuable information, the primary responsibility lies with the healthcare provider. Choice D is incorrect as referring the patient to another healthcare provider may disrupt continuity of care and not address the patient's concerns effectively.

Similar Questions