Nursing Elites

1. A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?

• A. Clamp the chest tube prior to transferring the client to a wheelchair.
• B. Disconnect the chest tube from the drainage system during transport.
• C. Keep the drainage system below the level of the client's chest at all times.
• D. Empty the collection chamber prior to transport.

Correct answer: C

Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.

2. When assessing a client with pneumonia, which clinical manifestation should the nurse expect to find?

• A. Fremitus
• B. Hyperresonance
• C. Dullness on percussion
• D. Decreased tactile fremitus

Correct answer: C

Rationale: In pneumonia, lung tissue consolidation occurs, leading to dullness on percussion. This is a typical finding in pneumonia. Fremitus and decreased tactile fremitus are more commonly associated with conditions like pleural effusion or pneumothorax. Hyperresonance is typically seen in conditions causing air trapping, such as emphysema.

3. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

• A. Pain severity
• B. Wound drainage
• C. Tissue integrity
• D. Airway patency

Correct answer: D

Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.

4. A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?

• A. Increase protein intake.
• B. Limit fluid intake to 1500 mL/day.
• C. Consume a low-sodium diet.
• D. Take a daily multivitamin.

Correct answer: C

Rationale: For a client with cirrhosis experiencing ascites, the nurse should instruct them to consume a low-sodium diet. This dietary modification helps reduce fluid retention and manage ascites by decreasing the amount of sodium in the body, which helps prevent fluid accumulation in the abdomen. Limiting sodium intake is crucial in managing ascites and preventing further complications in clients with cirrhosis.

5. A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

• A. Attending a class on tracheostomy care
• B. Verbally explaining all steps in the procedure
• C. Performing the procedure independently
• D. Asking relevant questions about suctioning

Correct answer: C

Rationale: When the partner can independently perform the suctioning procedure, it demonstrates a readiness for the client's discharge. This indicates that the partner has acquired the necessary skills and knowledge to provide safe care for the client at home without the direct supervision of healthcare professionals.

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