Nursing Elites

1. A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?

• A. Do nothing; this is a normal response
• B. Strip the tubing to remove any clots
• C. Place a clamp on the tube near the client's chest
• D. Remove the collection chamber and connect the tubing to a new device

Correct answer: C

Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately. Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak. Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action. Choice D is incorrect as it does not address the immediate need to locate and address the leak.

2. Which of the following is an example of low health literacy skills?

• A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
• B. A client cannot read an admission form to sign it
• C. A nurse cannot calculate the correct IV rate for Ringer's lactate
• D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine

Correct answer: B

Rationale: Low health literacy skills are exemplified by an individual's inability to comprehend health-related information. In this scenario, a client's inability to read an admission form to sign it indicates low health literacy. This lack of understanding can hinder their ability to make informed decisions about their healthcare. The other choices involve healthcare professionals and their knowledge or skills, not the health literacy of individuals seeking care.

3. What information should be collected when assessing the health status of a community?

• A. Air pollution levels
• B. Number of health food stores
• C. Most common causes of death
• D. Education level of the individuals

Correct answer: C

Rationale: When assessing the health status of a community, it is crucial to gather data on various health measures such as the most common causes of death. This information helps in understanding the prevalent health issues within the community. Factors like air pollution levels, the number of health food stores, and the education level of individuals are important community aspects but do not directly reflect the health status of the community. Therefore, the correct answer is to collect data on the most common causes of death as it provides insights into the major health concerns affecting the community.

4. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.

• A. nosocomial
• B. systemic
• C. resident flora
• D. resident aura

Correct answer: A

Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.

5. A client needs to give informed consent for electroconvulsive therapy treatments. Which of the following actions should the nurse take?

• A. Explain the adverse effects the client might experience from the treatment
• B. Verify the client gave consent voluntarily for the treatment
• C. Describe the benefits of the treatment to the client
• D. Outline possible alternatives to the treatment for the client

Correct answer: B

Rationale: When obtaining informed consent for a procedure like electroconvulsive therapy, the nurse's primary responsibility is to ensure that the client has given consent voluntarily and is capable of making such a decision. While it is essential to provide information on the treatment's benefits, risks, and alternatives, the priority is to verify the client's voluntary consent. Explaining the adverse effects and describing the benefits are important steps in the informed consent process, but the critical step is to confirm the client's voluntary agreement. Outlining possible alternatives to the treatment is also important but comes after ensuring the client's voluntary consent.

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