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 client with asthma is being admitted for breathing difficulties. His arterial blood gas results are pH 7.26, PCO2 49, PaO2 90, and HCO3- 21. Which of the following best describes this condition?

• A. Uncompensated respiratory acidosis
• B. Compensated respiratory alkalosis
• C. Uncompensated metabolic acidosis
• D. Compensated metabolic alkalosis

Correct answer: A

Rationale: In this case, the client's arterial blood gas results show a pH of 7.26 and a PCO2 of 49, both of which are abnormal. A pH below the normal range of 7.35-7.45 indicates acidosis. The elevated PCO2 of 49 mmHg suggests respiratory acidosis as the primary issue. The normal range for PCO2 is 35-45 mmHg, so a value of 49 indicates the retention of excess CO2, leading to acidosis. The low HCO3- level of 21 also supports the presence of metabolic acidosis; however, the primary abnormality is respiratory, making this an uncompensated respiratory acidosis. Therefore, the correct answer is 'Uncompensated respiratory acidosis.' Choice B, 'Compensated respiratory alkalosis,' is incorrect because the client's pH is acidic, not alkalotic. Additionally, there is no compensation occurring for the primary respiratory acidosis indicated by the elevated PCO2. Choice C, 'Uncompensated metabolic acidosis,' is incorrect because while the HCO3- level is low, the primary issue indicated by the elevated PCO2 is respiratory acidosis. Choice D, 'Compensated metabolic alkalosis,' is incorrect since the arterial blood gas results do not support a metabolic alkalosis. The low HCO3- level would typically be seen in metabolic acidosis, but in this case, the primary issue is respiratory acidosis.

3. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

• A. The adolescent gives away a DVD player and a cherished autographed picture of a performer.
• B. The adolescent runs out of group therapy, swearing at the group leader, and then goes to her room.
• C. The adolescent becomes angry while speaking on the phone and slams down the receiver.
• D. The adolescent gets angry with her roommate when the roommate borrows her clothes without asking.

Correct answer: A

Rationale: The correct answer is when the adolescent gives away a DVD player and a cherished autographed picture of a performer. This behavior is concerning because a depressed suicidal client often gives away things of value as a way of saying goodbye and wanting to be remembered. Choices B, C, and D all involve anger and acting-out behaviors, which are common in adolescents but do not specifically indicate suicidal ideation. Running out of group therapy, swearing, and going to her room, becoming angry and slamming the phone receiver, or getting upset when her roommate borrows her clothes are not clear indications of suicidal thoughts.

4. After a lengthy explanation of a medical procedure, the patient asks many questions. The physician answers all of the questions to the best of their ability. The patient then gives consent for treatment. The costly equipment and supplies are put into place, and the patient is prepared. Two minutes before the procedure is to start, the patient begins panicking and changes their mind. Which of the following situations would be the best way to avoid litigation?

• A. Document that the patient originally gave consent and proceed if the benefits of the procedure outweigh the patient's wishes.
• B. Have the patient sign a form stating that they are refusing consent. If they refuse to sign, do not proceed with the procedure.
• C. Repeat the explanation of the procedure until the patient understands that having the procedure done is the best form of treatment. Do not proceed with the procedure.
• D. Do not proceed. Document the patient's refusal, have the patient sign a refusal to consent to treatment. If the patient refuses to sign the form, have a witness available to sign.

Correct answer: D

Rationale: In this scenario, the best course of action to avoid litigation is to respect the patient's right to refuse treatment, especially when changing their mind before the procedure starts. By not proceeding with the treatment, documenting the patient's refusal, and having the patient sign a refusal to consent form, you are following proper ethical and legal procedures. If the patient refuses to sign the form, having a witness available to sign further strengthens the documentation of the patient's decision. This approach ensures that the patient's autonomy and right to make informed decisions about their healthcare are respected. Choices A, B, and C do not prioritize the patient's right to refuse treatment and could potentially lead to legal issues if treatment is carried out against the patient's wishes.

5. Teresa is an 84-year-old with stage 4 ovarian cancer who has been admitted for a bowel obstruction. She recently stated that she has decided that she doesn't want any further aggressive care and is requesting to be placed under hospice care. Her husband and daughter are supportive of her decision. She spoke with her oncologist about it, and he stated that he did not agree and wrote orders on her chart for chemotherapy. What would be the best first response to this situation?

• A. Give the patient a list of other oncologists
• B. Tell the family to report the doctor to the state quality board
• C. Notify the doctor that the patient refuses the chemotherapy
• D. Give the patient hospice information

Correct answer: C

Rationale: The patient has the right to refuse any treatment, and the doctor should be notified that the orders on the chart cannot be performed, with appropriate documentation. In this situation, the best first response is to notify the doctor that the patient refuses the chemotherapy. This step ensures that the patient's wishes are respected and that inappropriate treatments are not administered. It also opens up a dialogue with the oncologist, giving him the opportunity to understand the patient's perspective and potentially support her decision. Providing hospice information is a good follow-up step after addressing the immediate issue of refusing chemotherapy, as it allows the patient to initiate her own hospice evaluation if desired. Giving the patient a list of other oncologists or telling the family to report the doctor to the state quality board are not appropriate initial responses and may not align with the patient's wishes or autonomy.

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