Nursing Elites

1. A client with a chest tube following a pneumothorax is concerned about the continuous bubbling in the water seal chamber. What should the nurse explain to the client?

• A. Continuous bubbling in the water seal chamber indicates an air leak.
• B. Continuous bubbling is normal and expected with a chest tube.
• C. Bubbling will stop when the lung has fully expanded.
• D. The nurse should notify the healthcare provider immediately.

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.

2. Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?

• A. Call healthcare provider to request a different analgesic
• B. Determine when morphine can be given again
• C. Implement complementary pain relief methods
• D. Observe dressing to determine the presence of bleeding

Correct answer: C

Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (Choice A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (Choice B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (Choice D) is important but not the first priority when the client is experiencing unrelieved pain.

3. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the nurse plan to include in the child's plan of care?

• A. Recommend parents bring favorite snacks
• B. Encourage ambulation daily to the playroom
• C. Measure blood pressure every 4 to 6 hours
• D. Offer a selection of fresh fruit for each meal

Correct answer: C

Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. Monitoring blood pressure frequently is crucial in managing glomerulonephritis, as hypertension is a common complication during the acute edematous phase. Choice A is incorrect as it does not address the specific needs of a child with glomerulonephritis. Choice B is incorrect as excessive activity may not be suitable during the acute phase, as rest and monitoring are more important. Choice D is incorrect as the focus should be on monitoring vital signs rather than meal options.

4. Which of the following is an appropriate intervention for a patient experiencing a hypertensive crisis?

• A. Placing the patient in a supine position
• B. Administering a beta-blocker intravenously
• C. Encouraging the patient to drink fluids
• D. Applying a cold compress to the forehead

Correct answer: B

Rationale: Administering a beta-blocker intravenously is the correct intervention for a patient experiencing a hypertensive crisis. Beta-blockers help quickly reduce blood pressure and prevent complications such as stroke or heart attack. Placing the patient in a supine position can worsen the condition by reducing venous return and increasing the workload of the heart. Encouraging the patient to drink fluids is not recommended as it can exacerbate hypertension by increasing fluid volume. Applying a cold compress to the forehead does not address the underlying cause of the hypertensive crisis and is unlikely to provide significant benefit.

5. You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?

• A. 10
• B. 8
• C. 7
• D. 9

Correct answer: D

Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.

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