Nursing Elites

1. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following actions should the nurse take?

• A. Clamp the chest tube when assisting the client out of bed.
• B. Empty the drainage system every 8 hours.
• C. Keep the collection device below the client's chest.
• D. Strip the chest tube every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.

2. A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?

• A. Instill 500 ml of solution through the NG tube
• B. Insert a large-bore NG tube
• C. Use a cold irrigation solution
• D. Instruct the client to lie on his right side

Correct answer: B

Rationale: The correct answer is B: 'Insert a large-bore NG tube.' When performing a gastric lavage for a client with upper gastrointestinal bleeding, a large-bore NG tube is used to effectively remove gastric contents and blood. Option A is incorrect because the amount of solution to instill depends on the specific situation and should be guided by the healthcare provider's order. Option C is incorrect because using a cold irrigation solution can lead to hypothermia and is not recommended. Option D is incorrect as there is no need to instruct the client to lie on his right side specifically for gastric lavage.

3. A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. Bradycardia.
• C. Jugular vein distention.
• D. Dependent edema.

Correct answer: C

Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.

4. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?

• A. Assist the client in changing positions in bed
• B. Administer a PRN dose of morphine
• C. Encourage the client to use relaxation techniques
• D. Offer the client a back massage

Correct answer: B

Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.

5. A nurse is assessing a client who has acute pancreatitis. Which of the following findings should the nurse expect?

• A. Left upper quadrant pain.
• B. Periumbilical pain.
• C. Rebound tenderness.
• D. Flank pain.

Correct answer: A

Rationale: Corrected Rationale: The correct answer is A, left upper quadrant pain. In acute pancreatitis, inflammation of the pancreas commonly causes pain in the left upper quadrant of the abdomen. This pain can be severe and radiate to the back. Periumbilical pain (choice B) is more indicative of acute appendicitis. Rebound tenderness (choice C) is associated with peritoneal inflammation, not specifically pancreatitis. Flank pain (choice D) is more characteristic of conditions involving the kidneys or ureters, such as renal colic.

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