Nursing Elites

1. A nurse is assessing a client who has a chest tube and notes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client.
• B. Clamp the chest tube.
• C. Replace the drainage system.
• D. Apply a dressing over the insertion site.

Correct answer: D

Rationale: The correct action for the nurse to take when continuous bubbling is noted in the water seal chamber of a chest tube is to apply a dressing over the insertion site. Continuous bubbling indicates an air leak, and applying a dressing helps manage this issue by providing a seal. Clamping the chest tube or replacing the drainage system is not appropriate in this situation as it can lead to complications such as tension pneumothorax or inadequate drainage of the pleural space.

2. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Stay in bed for at least 1 hour if unable to fall asleep.
• B. Take a 1-hour nap during the day.
• C. Perform exercise before bed.
• D. Eat a light snack before bedtime.

Correct answer: D

Rationale: The correct answer is to eat a light snack before bedtime. Consuming a light snack can help promote sleep by preventing discomfort from hunger. Choice A is incorrect because staying in bed for too long when unable to fall asleep can lead to frustration and worsen insomnia. Choice B is incorrect as taking a nap during the day can interfere with nighttime sleep. Choice C is incorrect as exercising before bed can increase alertness and make falling asleep more difficult.

3. A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Crackles in the lung bases
• B. Oxygen saturation of 95%
• C. Heart rate of 88/min
• D. Frequent productive cough

Correct answer: A

Rationale: The correct answer is A: Crackles in the lung bases. In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, suggesting worsening respiratory status. This finding should be reported to the provider for further evaluation and management. Choice B, an oxygen saturation of 95%, is within the normal range and does not require immediate reporting. Choice C, a heart rate of 88/min, is also within normal limits and does not indicate an urgent need for intervention. Choice D, a frequent productive cough, is a common symptom in pneumonia and may not require immediate reporting unless it is severe or worsening. Therefore, crackles in the lung bases are the most concerning finding that warrants prompt attention.

4. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

5. A healthcare professional is reviewing the medical record of a client with schizophrenia. Which of the following findings should the professional report to the provider?

• A. Blood pressure: 102/56 mm Hg.
• B. Heart rate: 95/min.
• C. Sore throat.
• D. WBC count 14,000/mm^3.

Correct answer: D

Rationale: An elevated WBC count should be reported to the provider as it may indicate an infection. Elevated white blood cell counts can be a sign of an underlying infection or inflammation. Monitoring and reporting abnormal laboratory values are essential for timely interventions. The other options, such as blood pressure, heart rate, and a sore throat, while important for overall assessment, are not directly related to the potential medical urgency indicated by an elevated WBC count.

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