Nursing Elites

1. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A. Clamp the chest tube
• B. Call the surgeon immediately
• C. Prepare for blood transfusion
• D. Continue to monitor the rate of drainage

Correct answer: D

Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.

2. A nurse is reinforcing nutrition teaching with a client who has osteoporosis. Which of the following food selections should the nurse recommend to increase calcium in the client's diet?

• A. 1 medium apple
• B. 3 oz of lean beef
• C. 1 tbsp of cream cheese
• D. 1 cup of kale

Correct answer: D

Rationale: The correct answer is D: 1 cup of kale. Kale is rich in calcium, making it a suitable choice to increase calcium intake for individuals with osteoporosis. While fruits like apples (choice A) are nutritious, they are not high in calcium. Lean beef (choice B) is a good source of protein but not a significant source of calcium. Cream cheese (choice C) is also not a primary source of calcium compared to kale.

3. A client who is pregnant and has hyperemesis gravidarum is being taught about nutrition at home by a nurse. Which of the following statements indicate that the client understands the teachings?

• A. I will drink water with my meals.
• B. I will eat every 6 hours throughout the day.
• C. I will eat crackers before I get out of bed in the morning.
• D. I will limit my protein intake.

Correct answer: C

Rationale: The correct answer is C. Eating crackers before getting out of bed can help manage nausea associated with hyperemesis gravidarum. Choice A is incorrect because drinking water with meals may exacerbate nausea. Choice B is incorrect as eating every 6 hours may not be frequent enough to combat nausea and vomiting. Choice D is incorrect because protein intake should not be limited during pregnancy, especially in cases of hyperemesis gravidarum.

4. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

• A. Respiratory rate of 16 breaths per minute
• B. Blood pressure of 120/80 mm Hg
• C. Temperature of 99.5 degrees Fahrenheit
• D. Heart rate of 80 beats per minute

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

5. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?

• A. Auscultation of breath sounds
• B. Measurement of peak expiratory flow
• C. Observation of the client's use of accessory muscles
• D. Assessment of the client's skin color

Correct answer: A

Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.

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