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 nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?

• A. Assist a client post cerebral vascular accident to ambulate
• B. Feed a 2-year-old in balanced skeletal traction
• C. Care for a client with discharge orders
• D. Collect a sputum specimen for acid-fast bacillus

Correct answer: C

Rationale: Caring for a client with discharge orders involves tasks that require critical thinking and clinical judgment, which are beyond the scope of a UAP. Delegating this task to a UAP can compromise patient safety and outcomes. The correct answer is C. Choices A, B, and D are appropriate tasks to delegate to a UAP based on their training and scope of practice. Assisting a client to ambulate, feeding a pediatric patient in traction, and collecting a sputum specimen are tasks that can be safely performed by a UAP under appropriate supervision.

3. The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?

• A. Encourage the client to ambulate
• B. Apply a warm compress to the left leg
• C. Elevate the client's left leg
• D. Administer a prescribed anticoagulant

Correct answer: C

Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.

4. When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?

• A. Reports of leg cramping at rest
• B. Family history of heart disease
• C. Current use of beta-blockers
• D. History of intermittent claudication

Correct answer: D

Rationale: Corrected Rationale: Intermittent claudication, or pain in the legs while walking that is relieved by rest, is a classic symptom of peripheral arterial insufficiency. Other factors such as a family history or medication use may contribute to cardiovascular health, but claudication is the most specific indicator. Leg cramping at rest is more indicative of conditions like peripheral neuropathy or deep vein thrombosis. Family history of heart disease and current use of beta-blockers are relevant to overall cardiovascular health, but they are not as directly related to chronic peripheral arterial insufficiency as intermittent claudication.

5. A client is being prepared for surgery and has been placed on NPO status. Which of the following is the nurse's priority assessment?

• A. Assess the client's understanding of the procedure
• B. Monitor the client's compliance with NPO status
• C. Check the client's vital signs
• D. Ensure the client's consent form is signed

Correct answer: B

Rationale: The correct answer is B. Monitoring the client's compliance with NPO status is the priority assessment. Ensuring the client remains NPO (nothing by mouth) is crucial to reduce the risk of aspiration during surgery. Assessing the client's understanding of the procedure is important but not the priority at this moment. Checking vital signs is also essential but ensuring NPO status takes precedence for patient safety. Ensuring the client's consent form is signed is necessary but not the priority assessment compared to maintaining NPO status.

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