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 healthcare professional is caring for a client who has a new prescription for metformin. Which of the following laboratory results should the healthcare professional review before administering the medication?

• A. Potassium
• B. Serum creatinine
• C. Sodium
• D. Hemoglobin A1C

Correct answer: B

Rationale: Correct Answer: The healthcare professional should review serum creatinine levels before administering metformin to assess kidney function. Metformin is excreted by the kidneys, and checking serum creatinine helps prevent lactic acidosis, a potential side effect in individuals with impaired renal function. Choice A: Potassium levels are not directly related to the administration of metformin. While monitoring potassium levels is important for some medications, it is not the priority when initiating metformin. Choice C: Sodium levels are not typically assessed specifically before starting metformin. It is not a routine lab test required prior to metformin administration. Choice D: Hemoglobin A1C reflects long-term blood sugar control and is not a lab test that needs to be reviewed before initiating metformin. It is used to monitor diabetes management over time, not for immediate medication administration considerations.

3. A nurse is caring for a client who has Raynaud's disease. Which action should the nurse take?

• A. Provide information about stress management.
• B. Maintain a warm temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Raynaud's disease is to provide information about stress management. Raynaud's disease is a condition where the blood vessels narrow in response to cold or stress, leading to reduced blood flow to certain areas of the body, usually the fingers and toes. Stress management helps reduce triggers for Raynaud's disease by minimizing emotional stress, which can trigger vasospasms. Choice B is incorrect as maintaining a warm temperature, rather than a cool one, is recommended for individuals with Raynaud's disease to prevent triggering vasospasms. Choice C is incorrect because epinephrine is not typically used to manage Raynaud's disease, as it can further constrict blood vessels. Choice D is incorrect as glucocorticoid steroids are not a first-line treatment for Raynaud's disease.

4. A nurse is providing discharge teaching to a client who has a new prescription for lisinopril. Which of the following instructions should the nurse include?

• A. Take this medication in the morning.
• B. You may experience a persistent cough while taking this medication.
• C. Avoid taking this medication with a potassium supplement.
• D. Take this medication with a full glass of water.

Correct answer: B

Rationale: The correct answer is B: 'You may experience a persistent cough while taking this medication.' Lisinopril is known to cause a persistent cough as a common side effect. It is essential for the nurse to educate the client about this potential side effect, as it should be reported to the healthcare provider. Choice A is incorrect because lisinopril is usually taken once daily, but not necessarily at bedtime. Choice C is incorrect because lisinopril can actually increase potassium levels, so taking it with a potassium supplement may lead to hyperkalemia. Choice D is incorrect because antacids may reduce the effectiveness of lisinopril, so it should not be taken with them.

5. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Avoid eating spinach while taking this medication.
• B. Massage the injection site after administration.
• C. Administer the injection into the deltoid muscle.
• D. Inject the medication into the abdomen.

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

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