Nursing Elites

1. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

• A. Apply a pressure dressing around the chest tube site.
• B. Administer an oral antihistamine.
• C. Assess for allergies to topical cleaning agents.
• D. Measure the area of swelling and crackling.

Correct answer: D

Rationale: When a nurse observes crepitus around a chest tube site, it could indicate subcutaneous emphysema, a potentially serious condition where air gets trapped under the skin. Measuring the area of swelling and crackling is important as it helps monitor the progression of subcutaneous emphysema. Applying a pressure dressing (choice A) might not address the underlying cause and could potentially worsen the condition. Administering an oral antihistamine (choice B) is not indicated for crepitus at a chest tube site. Assessing for allergies to topical cleaning agents (choice C) is important but not the immediate priority when crepitus is observed.

2. A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?

• A. Mild impairment
• B. Moderate impairment
• C. Severe impairment
• D. Normal

Correct answer: B

Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring. A GCS score of 10 suggests that the client is moderately impaired neurologically. Choices A, C, and D are incorrect because a GCS score of 10 does not indicate mild impairment, severe impairment, or normal neurological status, respectively.

3. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?

• A. Administer an antihistamine as prescribed.
• B. Stop the infusion and notify the healthcare provider.
• C. Slow the infusion rate and monitor the client.
• D. Administer epinephrine subcutaneously.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.

4. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions are most important for the nurse to include in the discharge plan?

• A. Teach signs of infection
• B. Teach tracheal suctioning techniques
• C. Educate on humidifying air
• D. Discuss the use of a speaking valve

Correct answer: B

Rationale: The correct answer is B: Teach tracheal suctioning techniques. Tracheal suctioning is crucial for maintaining a clear airway in clients with a tracheostomy. Without proper suctioning, secretions can accumulate and cause airway obstruction or respiratory infections. Educating the client on how to perform suctioning safely is a priority for discharge planning. Choices A, C, and D are important aspects of tracheostomy care, but teaching tracheal suctioning techniques takes precedence due to its direct impact on airway patency and preventing complications.

5. A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?

• A. Limit sodium intake to 2 grams per day.
• B. Choose fresh fruits and vegetables.
• C. Drink at least 8 glasses of water daily.
• D. Avoid processed foods and canned soups.

Correct answer: D

Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.

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