Nursing Elites

1. A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?

• A. Call the Rapid Response Team.
• B. Document and continue to monitor.
• C. Notify the primary care provider.
• D. Repeat blood pressure measurement in 15 minutes.

Correct answer: A

Rationale: In this scenario, the significant drop in blood pressure indicates a potential emergency situation. The correct action is to call the Rapid Response Team (RRT) to ensure prompt intervention and prevent further deterioration that could lead to respiratory or cardiac arrest. It is crucial to act swiftly in response to such a critical change in vital signs to provide the client with the necessary care and support.

2. A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?

• A. Bowel sounds
• B. Surgical dressing
• C. Temperature
• D. Oxygen saturation

Correct answer: D

Rationale: The priority assessment for a client being admitted to the surgical unit following a cholecystectomy is oxygen saturation. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and ventilation, especially after surgery. Hypoxia can have serious consequences and needs to be promptly addressed. While assessing bowel sounds, surgical dressing, and temperature are important, oxygen saturation takes precedence in this situation.

3. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

• A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
• B. Assess for an increase in temperature.
• C. Check the oximeter.
• D. Monitor for manifestations of increased intracranial pressure.

Correct answer: C

Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.

4. A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?

• A. Holding the device securely when changing ties
• B. Suctioning the client first if secretions are present
• C. Tying a square knot at the back of the neck
• D. Using half-strength peroxide for cleansing

Correct answer: C

Rationale: When providing tracheostomy care, it is important to ensure the client's safety and prevent pressure ulcers. When securing ties that require knotting, the knot should be placed at the side of the client's neck, not at the back. Tying a square knot at the back of the neck could lead to discomfort, pressure ulcers, or accidental tightening. Holding the device securely, suctioning the client as needed, and using appropriate cleansing solutions are all essential components of tracheostomy care.

5. A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?

• A. Clamp the tube when the client is ambulating.
• B. Keep the collection device below the level of the client's chest.
• C. Carefully coil the tubes to prevent kinking.
• D. Position the client flat to avoid leaks in the tubing.

Correct answer: B

Rationale: Keeping the collection device below the level of the client's chest ensures proper drainage and prevents backflow of fluid into the patient's chest. This position allows gravity to assist in the drainage process. Clamping the tube when the client is ambulating can cause a buildup of pressure in the chest drainage system, potentially leading to complications. Carefully coiling the tubes is important to prevent obstructions and kinks that could impede the flow of drainage. Positioning the client flat may not be ideal as it could hinder proper drainage and increase the risk of leaks in the tubing.

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