Nursing Elites

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

• A. Drainage of 75 mL in the past 24 hours.
• B. Intermittent bubbling in the water seal chamber.
• C. Continuous bubbling in the water seal chamber.
• D. Tidaling in the water seal chamber.

Correct answer: C

Rationale: Continuous bubbling in the water seal chamber should be reported to the provider as it can indicate an air leak. This finding suggests that air is escaping from the pleural space, which can lead to lung collapse or pneumothorax. Drainage of 75 mL in the past 24 hours is within the expected range for a client with a chest tube and is not a cause for concern. Intermittent bubbling in the water seal chamber is a normal finding that indicates the system is functioning properly. Tidaling in the water seal chamber is also an expected finding that shows the fluctuation of fluid with the client's breathing and is not alarming.

2. A nurse is caring for a client who has a prescription for a high-protein diet. Which of the following foods should the nurse recommend?

• A. Almonds
• B. Cheddar cheese
• C. Chicken breast
• D. Pasta

Correct answer: C

Rationale: Chicken breast is an excellent choice for a high-protein diet as it is a lean source of protein. Almonds, while a good source of protein, also contain high amounts of fat. Cheddar cheese is high in protein but also high in saturated fat. Pasta is not a significant source of protein compared to chicken breast.

3. A healthcare professional is assessing a client who is 24 hours postoperative following an open cholecystectomy. Which of the following findings should the healthcare professional report to the provider?

• A. Urinary output of 100 mL in 4 hours
• B. Serosanguineous wound drainage
• C. Heart rate of 94/min
• D. WBC count of 15,000/mm³

Correct answer: D

Rationale: A WBC count of 15,000/mm³ is elevated and may indicate infection, which should be reported. High WBC count is a sign of inflammation or infection, and in a postoperative client, it can be indicative of surgical site infection or another complication. Urinary output, serosanguineous wound drainage, and a heart rate of 94/min are all within normal ranges for a client post cholecystectomy and do not raise immediate concerns for infection or complications.

4. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

• A. Blow as hard as possible into the mouthpiece.
• B. Exhale quickly and forcefully after taking a deep breath.
• C. Inhale as deeply as possible and then blow into the mouthpiece.
• D. Take a deep breath and hold it for 5 seconds before exhaling.

Correct answer: B

Rationale: The correct answer is B because the client should exhale quickly and forcefully into the peak flow meter after taking a deep breath to measure peak expiratory flow. Choice A is incorrect as blowing as hard as possible may not provide an accurate reading. Choice C is incorrect because inhaling deeply before blowing can affect the results. Choice D is incorrect as holding the breath before exhaling is not part of using a peak flow meter.

5. A client has Clostridium difficile infection. Which of the following actions should the nurse take?

• A. Wash hands with an alcohol-based hand rub.
• B. Place the client on contact precautions.
• C. Wear a mask when entering the client's room.
• D. Double-bag all linens before removing them from the room.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.

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