Nursing Elites

1. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

• A. The client who has been NPO since midnight for endoscopy
• B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
• C. The client who has end-stage renal failure and is scheduled for dialysis today
• D. The client who has gastroenteritis and is febrile

Correct answer: D

Rationale: Gastroenteritis can lead to fluid loss through vomiting and diarrhea, especially when accompanied by fever. Fever can increase insensible water loss through sweating as well. Both vomiting and diarrhea can significantly contribute to fluid volume deficit, making the client with gastroenteritis and fever at higher risk compared to the other clients described in the options.

2. A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?

• A. Pertussis
• B. Mycoplasma pneumonia
• C. Tuberculosis
• D. Respiratory syncytial virus

Correct answer: C

Rationale: An OSHA-approved N95 respirator mask is recommended when caring for a client with tuberculosis due to the airborne transmission of the disease. Tuberculosis poses a higher risk of transmission via respiratory droplets, making respiratory protection essential to prevent exposure and infection among healthcare workers.

3. A healthcare professional wishes to provide client-centered care in all interactions. Which action by the healthcare professional best demonstrates this concept?

• A. Assesses for cultural influences affecting healthcare
• B. Ensures that all the client's basic needs are met
• C. Informs the client and family about all upcoming tests
• D. Thoroughly orients the client and family to the room

Correct answer: A

Rationale: Client-centered care focuses on individualizing care to meet the client's unique needs, preferences, and values. Assessing for cultural influences affecting healthcare allows the healthcare professional to provide culturally sensitive and competent care, respecting the client's beliefs and practices. It promotes effective communication, understanding, and collaboration, essential components of client-centered care.

4. The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

• A. Fluctuation of the fluid level within the water seal chamber
• B. Absence of fluid in the drainage tubing
• C. Continuous bubbling within the water seal chamber
• D. Equal amounts of fluid drainage in each collection chamber

Correct answer: A

Rationale: Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.

5. A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?

• A. Stridor
• B. Copious oral secretions
• C. Hoarseness
• D. Sore throat

Correct answer: A

Rationale: Stridor is a high-pitched, harsh respiratory sound that can indicate airway obstruction. It is a serious finding that requires immediate attention as it may lead to respiratory compromise. Copious oral secretions, hoarseness, and sore throat are common but expected findings after endotracheal tube removal and do not typically require urgent intervention.

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