Nursing Elites

1. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?

• A. Clamp the tube if there is excessive drainage
• B. Empty the drainage chamber every 2 hours
• C. Keep the drainage system below chest level
• D. Milk the tube to prevent clots from forming

Correct answer: C

Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.

2. The nurse is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?

• A. The client will maintain adequate nutrition.
• B. The client will manage side effects of treatment.
• C. The client will recognize signs and symptoms of infection.
• D. The client will experience a reduction in pain.

Correct answer: C

Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.

3. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide to the client?

• A. Avoid leafy green vegetables while taking warfarin.
• B. Report any unusual bruising or bleeding.
• C. Take warfarin at the same time every day.
• D. Avoid alcohol consumption while on warfarin.

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol consumption while on warfarin.' Alcohol can increase the risk of bleeding when taken with warfarin, so it should be avoided. Choice A is incorrect as leafy green vegetables contain vitamin K, which can interfere with the anticoagulant effects of warfarin. Choice B is important but not directly related to alcohol consumption. Choice C is a general instruction for medication adherence but not specifically related to the interaction with alcohol.

4. A client with hypothyroidism is prescribed levothyroxine. What instruction should the nurse provide?

• A. Take the medication in the morning before eating.
• B. Take the medication with a full glass of water.
• C. Take the medication with food to avoid nausea.
• D. Take the medication only when symptoms worsen.

Correct answer: A

Rationale: The correct answer is A: 'Take the medication in the morning before eating.' Levothyroxine should be taken on an empty stomach in the morning for optimal absorption. Choice B is incorrect because while taking medication with water is generally recommended, levothyroxine specifically needs to be taken on an empty stomach. Choice C is incorrect as taking levothyroxine with food can interfere with its absorption. Choice D is incorrect as levothyroxine should be taken regularly as prescribed, not only when symptoms worsen.

5. A client with antisocial personality disorder repeatedly requests a specific nurse be assigned to him and is belligerent when another nurse is assigned. What action should the charge nurse implement?

• A. Remind the client that nurse assignments are not based on patient requests
• B. Assign the nurse requested by the client to avoid further conflict
• C. Tell the client that he can request a different nurse if unhappy
• D. Explain the situation calmly and reinforce the rules regarding nurse assignments

Correct answer: A

Rationale: The correct action for the charge nurse to implement is to remind the client that nurse assignments are not based on patient requests. In this situation, it is essential to establish boundaries and communicate that nurse assignments are made based on clinical decisions, not patient preferences. Option B is incorrect because it compromises the principle of fairness in nurse assignments. Option C is incorrect as it encourages the client's behavior by allowing him to request a different nurse based on personal preferences. Option D is also incorrect as it does not address the issue of patient manipulation and reinforces inappropriate behavior.

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