Nursing Elites

1. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?

• A. Ensure the client is fasting before the test
• B. Provide a warm blanket for the client
• C. Apply cold compresses to the client's chest
• D. Instruct the client to remain still

Correct answer: D

Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.

2. A healthcare provider is providing discharge instructions to a client with home oxygen. What is the most important safety consideration?

• A. Restrict fluid intake while using oxygen
• B. Ensure oxygen tanks are kept upright and away from heat sources
• C. Allow family members to smoke in designated areas
• D. Store oxygen tanks in a closet when not in use

Correct answer: B

Rationale: The correct answer is to ensure oxygen tanks are kept upright and away from heat sources. This is crucial to prevent any potential fire hazard, as oxygen supports combustion. Restricting fluid intake while using oxygen (choice A) is not necessary for oxygen safety. Allowing family members to smoke in designated areas (choice C) poses a significant fire risk. Storing oxygen tanks in a closet when not in use (choice D) is unsafe because proper ventilation is needed to prevent oxygen accumulation.

3. A nurse is caring for a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the first hour after surgery.
• B. Constant bubbling in the water seal chamber.
• C. Tidaling in the water seal chamber.
• D. Client report of pain at the chest tube insertion site.

Correct answer: B

Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.

4. When should a nurse suction a client with a tracheostomy?

• A. Every 6 hours, regardless of distress signs
• B. When the client's respiratory rate drops below 10
• C. When the client shows signs of irritability
• D. When the client begins to cough or show signs of airway blockage

Correct answer: C

Rationale: The correct answer is to suction the client when they show signs of irritability. Signs of irritability, such as restlessness or agitation, can indicate the need for suctioning in a client with a tracheostomy. This early indicator suggests that there may be an accumulation of secretions affecting the client's airway. Suctioning should be performed promptly to maintain a clear airway and prevent complications. Choices A, B, and D are incorrect because suctioning should be based on clinical signs and symptoms indicating the need for intervention, rather than a fixed schedule or specific vital sign parameters.

5. What is the most appropriate response when a client wants to discontinue dialysis?

• A. Ask the client why they want to discontinue.
• B. Instruct the client to focus on self-care.
• C. Offer to call the provider to cancel dialysis.
• D. Seek clarification and establish understanding.

Correct answer: D

Rationale: When a client expresses the desire to discontinue dialysis, the most appropriate response is to seek clarification and establish understanding. This approach allows the healthcare provider to comprehend the client's concerns, provide support, and engage in a collaborative decision-making process. Choice A, asking the client why they want to discontinue, can be perceived as confrontational and may not effectively address the underlying reasons. Instructing the client to focus on self-care (Choice B) may overlook the client's autonomy and decision-making capacity. Offering to call the provider to cancel dialysis (Choice C) does not actively involve the client in the decision-making process or address their concerns adequately.

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