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. A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

• A. Family history of heart disease
• B. Overweight
• C. Smoking
• D. Age

Correct answer: A

Rationale: A family history of heart disease is an inherited risk factor for developing atherosclerosis. This factor is not modifiable through lifestyle changes. Studies have shown that having a first-degree relative with heart disease significantly increases the individual's risk of developing atherosclerosis. Overweight, smoking, and age are not hereditary risk factors for atherosclerosis. Overweight and smoking are lifestyle-related risk factors, while age is a non-modifiable risk factor that increases with time but is not directly inherited.

3. 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.

4. A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?

• A. Small blue-white spots are visible on the oral mucosa.
• B. The rash begins on the trunk and spreads outward.
• C. There is low-grade fever.
• D. The lesions have a "teardrop-on-a-rose-petal"? appearance.

Correct answer: A

Rationale: The presence of small blue-white spots on the oral mucosa, known as Koplik's spots, is characteristic of measles (rubeola) infection. These spots typically appear on the buccal mucosa opposite the second molars, 1-2 days before the rash onset, and last until 2 days after the rash appears. While Koplik's spots are pathognomonic for measles, their absence does not rule out the diagnosis. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because the rash pattern, presence of low-grade fever, and characteristic appearance of lesions are not specific indicators of measles infection.

5. The priority goal for a family who practices Chinese medicine would be to:

• A. Achieve harmony
• B. Maintain a balance of energy
• C. Respect life
• D. Restore yin and yang

Correct answer: D

Rationale: In Chinese medicine, the concept of yin and yang represents the balance of opposing forces in the body. When there is an imbalance between yin and yang, it can result in illness. Therefore, the priority goal for a family practicing Chinese medicine would be to restore the harmony and balance between yin and yang. Choices A, B, and C are not the priority goal in Chinese medicine. While achieving harmony, maintaining a balance of energy, and respecting life are important aspects of Chinese medicine, the fundamental principle revolves around maintaining the equilibrium of yin and yang for optimal health.

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