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 nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?

• A. Restrict the client's fluid intake.
• B. Monitor the client's deep-tendon reflexes.
• C. Place the client in the lithotomy position.
• D. Encourage the client to ambulate frequently.

Correct answer: B

Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.

3. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

• A. Irrigate the nasogastric tube with distilled water
• B. Aspirate the gastric contents with a syringe
• C. Administer an antiemetic medication
• D. Insert a new nasogastric tube

Correct answer: B

Rationale: The most appropriate nursing intervention when a client with a nasogastric tube experiences nausea and a decrease in gastric secretions is to aspirate the gastric contents with a syringe. This action helps relieve nausea by removing excess fluid and gas. Option A, irrigating the nasogastric tube with distilled water, is not indicated as it does not address the underlying issue of decreased gastric secretions. Option C, administering an antiemetic medication, may provide symptomatic relief but does not address the mechanical issue of decreased flow in the nasogastric tube. Option D, inserting a new nasogastric tube, is not necessary unless there are specific complications or obstructions in the current tube.

4. What are the key signs of infection after surgery?

• A. Redness
• B. Swelling
• C. Fever
• D. All of the above

Correct answer: D

Rationale: After surgery, key signs of infection include redness, swelling, and fever. Redness and swelling can indicate inflammation at the surgical site, while fever is a systemic response to infection. Choosing 'All of the above' (Option D) is the correct answer because all three signs are commonly associated with post-surgical infections. Options A, B, and C are incorrect as each of them individually can be a sign of infection, but considering all three together provides a more comprehensive assessment for post-operative infection.

5. What is the priority for the nurse when caring for a patient with a chest tube?

• A. Ensure tube patency and observe for air leaks
• B. Maintain sterile technique during dressing changes
• C. Monitor drainage and record output
• D. Observe for signs of infection and monitor for subcutaneous emphysema

Correct answer: A

Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.

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