Nursing Elites

1. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

2. How should fluid balance in a patient with heart failure be monitored?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

3. A nurse is preparing to administer an IV medication to a client who has an allergy to latex. Which of the following actions should the nurse take?

• A. Use latex gloves when administering the medication.
• B. Use latex-free syringes when administering the medication.
• C. Administer the medication through a latex-free IV port.
• D. Administer the medication with a latex-free syringe.

Correct answer: C

Rationale: The correct action for the nurse to take when preparing to administer IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This is crucial as it prevents direct contact of the medication with latex, reducing the risk of an allergic reaction. Choice A is incorrect as using latex gloves can still expose the client to latex. Choice B is not the best option since the administration route is not specified, and using a latex-free syringe alone may not be sufficient to prevent exposure. Choice D is not the most appropriate because the IV tubing and ports should also be latex-free to ensure complete avoidance of latex contact.

4. A nurse is preparing to administer an IV medication to a client who reports a latex allergy. Which of the following actions should the nurse take?

• A. Place the client in a supine position.
• B. Use non-latex gloves when administering the medication.
• C. Use latex-free syringes when administering the medication.
• D. Administer the medication through a latex-free IV port.

Correct answer: D

Rationale: The correct action the nurse should take when preparing to administer an IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This measure helps prevent allergic reactions in clients with a known latex allergy. Placing the client in a supine position (Choice A) is not directly related to preventing a latex allergy reaction. Using non-latex gloves (Choice B) is important for protecting the nurse or caregiver from latex exposure but does not prevent the client's allergic reaction. While using latex-free syringes (Choice C) is a good practice, ensuring the IV port is latex-free is more crucial in preventing an allergic response in the client.

5. A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the past 24 hours.
• B. Intermittent bubbling in the water seal chamber.
• C. Continuous bubbling in the water seal chamber.
• D. Tidaling in the water seal chamber.

Correct answer: C

Rationale: Continuous bubbling in the water seal chamber should be reported to the provider as it can indicate an air leak. This finding suggests that air is escaping from the pleural space, which can lead to lung collapse or pneumothorax. Drainage of 75 mL in the past 24 hours is within the expected range for a client with a chest tube and is not a cause for concern. Intermittent bubbling in the water seal chamber is a normal finding that indicates the system is functioning properly. Tidaling in the water seal chamber is also an expected finding that shows the fluctuation of fluid with the client's breathing and is not alarming.

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