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 client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care?

• A. Right lower abdominal pain
• B. Confusion
• C. Depression
• D. Peripheral neuropathy

Correct answer: B

Rationale: Confusion is a key symptom of Wernicke’s syndrome, which is due to thiamine deficiency. Wernicke’s syndrome is characterized by a triad of symptoms known as the classic triad, which includes confusion, ataxia, and ophthalmoplegia. Right lower abdominal pain, depression, and peripheral neuropathy are not typically associated with Wernicke’s syndrome, making them incorrect choices for this question.

3. Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?

• A. The client was medicated for pain with a narcotic analgesic IM 6 hours ago
• B. A 15-year-old primigravida who has been self-supporting for the past 6 months
• C. The obstetrician explained a procedure that a neurologist will perform
• D. The client is illiterate but verbalizes understanding and consent for the procedure

Correct answer: D

Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.

4. When lactulose (Cephulac) 30 ml QID is prescribed for a male client with advanced cirrhosis, and he complains that it causes diarrhea, what action should the nurse take in response to the client’s statement?

• A. Explain that diarrhea is expected, but the drug reduces ammonia levels
• B. Document that the client is non-compliant with his treatment plan
• C. Tell the client to be concerned about more significant side effects of this drug
• D. Obtain a prescription for loperamide (Imodium) 4mg PO PRN diarrhea

Correct answer: A

Rationale: The correct answer is A. Diarrhea is an expected side effect of lactulose when used to reduce ammonia levels in cirrhosis. It helps in decreasing the absorption of ammonia in the colon, thereby reducing its levels in the blood. Option B is incorrect because it is essential for the nurse to educate the client about the expected side effects of the medication rather than assuming non-compliance. Option C is incorrect as it instills unnecessary fear in the client by suggesting more significant side effects without addressing the current concern. Option D is incorrect as loperamide should not be given automatically for diarrhea caused by lactulose, as the diarrhea is a therapeutic effect of the medication in this context.

5. The charge nurse of a cardiac telemetry unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client should be assigned to the RN?

• A. One day after a permanent pacemaker insertion, a client's telemetry monitor shows a pacer rhythm.
• B. Two hours after undergoing cardioversion, a client's telemetry monitor shows a normal sinus rhythm.
• C. A client started on carvedilol the previous day for heart failure has controlled atrial fibrillation.
• D. Four hours after admission, a client with syncope shows complete heart block on the telemetry monitor.

Correct answer: D

Rationale: The correct answer is D because complete heart block is a critical condition that requires immediate assessment and management by a registered nurse (RN). In complete heart block, there is a significant conduction disturbance that can lead to serious complications. The RN is better equipped to handle such complex and potentially life-threatening situations. Choices A, B, and C involve less critical conditions that can be managed by a practical nurse (PN) under the supervision of the RN. Therefore, assigning the client with complete heart block to the RN ensures prompt and appropriate intervention.

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