Nursing Elites

1. A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?

• A. Clamp the chest tube intermittently.
• B. Keep the drainage system below chest level.
• C. Empty the drainage chamber every 4 hours.
• D. Apply sterile gauze around the insertion site daily.

Correct answer: B

Rationale: To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.

2. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

• A. Why do you think your life isn’t worth living anymore?
• B. Do you have a plan to end your life?
• C. I need to understand what you mean by misery.
• D. You can trust me to share your thoughts.

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

3. A nurse is caring for a client who has acute pancreatitis. Which of the following laboratory findings should the nurse expect?

• A. Decreased serum amylase
• B. Decreased serum lipase
• C. Elevated blood glucose
• D. Elevated calcium levels

Correct answer: C

Rationale: In acute pancreatitis, the nurse should expect elevated blood glucose levels. This is due to impaired insulin production by the inflamed pancreas. While serum amylase and lipase levels are typically elevated in acute pancreatitis, blood glucose levels are also affected due to the pancreatic dysfunction. Therefore, choices A and B are incorrect. Elevated calcium levels are not typically associated with acute pancreatitis, making choice D incorrect.

4. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?

• A. Fever
• B. Rash
• C. Fatigue
• D. Increased appetite

Correct answer: B

Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.

5. A client is being taught about the use of levothyroxine. Which of the following should be included?

• A. It should be taken on an empty stomach
• B. Monitor for signs of hyperthyroidism
• C. It is a pain reliever
• D. It should be taken in the morning

Correct answer: B

Rationale: When educating a client about levothyroxine, it is important to emphasize the need to monitor for signs of hyperthyroidism. Levothyroxine should be taken on an empty stomach, preferably in the morning, to maximize its absorption. Choice A is incorrect as it should not be taken with food. Choice C is incorrect as levothyroxine is not a pain reliever. Choice D is incorrect as levothyroxine is usually taken in the morning.

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