Nursing Elites

1. While changing a client’s chest tube dressing, the nurse notes a crackling 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 insertion site
• B. Assess the client for allergies to topical cleaning agents
• C. Measure the area of swelling and crackling
• D. Administer an oral antihistamine per PRN protocol

Correct answer: A

Rationale: A crackling sensation indicates subcutaneous emphysema, caused by air trapped under the skin. Applying a pressure dressing around the chest tube insertion site can help manage the issue by preventing further air leakage into the tissues. Choice B is incorrect because the crackling sensation is not related to allergies. Choice C is incorrect as measuring the area does not address the underlying cause. Choice D is incorrect as administering an oral antihistamine is not indicated for subcutaneous emphysema.

2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad.' In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Feed the client a snack
• B. Empty the urinary drainage bag
• C. Offer the client oral fluids
• D. Stroke secondary to hemorrhage

Correct answer: D

Rationale: Elevated blood pressure, if left uncontrolled, significantly increases the risk of stroke secondary to hemorrhage and other cardiovascular events. This condition can lead to serious complications due to the increased pressure on the blood vessels in the brain. Choices A, B, and C are unrelated to the potential pathophysiological consequences of uncontrolled hypertension and are not the primary concern in this scenario.

3. Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?

• A. Place a pulse oximeter on the heel
• B. Swaddle the infant in a warm blanket
• C. Record the findings on the flow sheet
• D. Check the vital signs in 15 minutes

Correct answer: C

Rationale: The correct action for the nurse to take in this scenario is to record the findings on the flow sheet. The newborn's axillary temperature, heart rate, and respiratory rate are within normal limits for a 3-hour-old newborn. Therefore, there is no immediate need for intervention or further assessment. Swaddling the infant in a warm blanket, placing a pulse oximeter on the heel, or checking the vital signs in 15 minutes are not necessary actions based on the normal assessment findings presented. These actions could potentially disrupt the newborn or lead to unnecessary interventions when the baby is stable.

4. An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client’s spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?

• A. Reassure the spouse that the client will be well cared for and provide information about the facility’s care practices.
• B. Inform the spouse that care will be adjusted based on the client’s condition and needs.
• C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
• D. Suggest that the spouse speak with other family members for reassurance.

Correct answer: A

Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility’s care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.

5. Following a thyroidectomy, a client experiences tetany. The nurse should expect to administer which intravenous medication?

• A. Sodium iodide solution
• B. Levothyroxine sodium (Synthroid)
• C. Calcium gluconate
• D. Propranolol (Inderal)

Correct answer: C

Rationale: Following a thyroidectomy, tetany can occur due to hypoparathyroidism, leading to low calcium levels. Therefore, the nurse should administer calcium gluconate intravenously to raise the calcium levels. Choice A, Sodium iodide solution, is incorrect as it is used for thyroid conditions, not for treating tetany. Choice B, Levothyroxine sodium (Synthroid), is incorrect as it is a thyroid hormone replacement and does not address low calcium levels. Choice D, Propranolol (Inderal), is incorrect as it is a beta-blocker used for conditions like hypertension and not indicated for tetany after thyroidectomy.

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