Nursing Elites

1. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?

• A. Consider it a normal finding.
• B. Check the system for leaks.
• C. Clamp the chest tube.
• D. Change the drainage system.

Correct answer: A

Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.

2. When assessing a client's risk for elimination impairment, which of the following factors is least relevant?

• A. current medications
• B. ambulation abilities
• C. family history
• D. hydration status

Correct answer: C

Rationale: When assessing a client's risk for elimination impairment, family history is the least relevant factor to consider. Current medications can affect elimination functions through side effects, ambulation abilities can impact mobility to access toileting facilities, and hydration status directly influences urinary output and bowel function. Family history, although providing some context, does not have a direct impact on the client's current risk of elimination impairment.

3. The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?

• A. Administering the medication
• B. Drawing up the medication in a syringe
• C. Planning to have the nurse on the next shift administer the medication
• D. Contacting the healthcare provider

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.

4. How often should physical restraints be released?

• A. Every 2 hours
• B. Between 1 and 3 hours
• C. Every 30 minutes
• D. At least every 4 hours

Correct answer: A

Rationale: The correct answer is to release physical restraints every 2 hours. Releasing restraints every 2 hours helps prevent complications associated with prolonged immobilization. Releasing restraints every 30 minutes (choice C) may be too frequent and disruptive to the client's care. Releasing restraints between 1 and 3 hours (choice B) introduces variability that could lead to inconsistencies in care. Releasing restraints at least every 4 hours (choice D) does not adhere to the recommended frequency of every 2 hours.

5. How does cancer affect pain tolerance in elderly clients?

• A. Remain constant.
• B. Decrease.
• C. Increase.
• D. Cancer has no impact on pain tolerance in elderly clients.

Correct answer: B

Rationale: Pain tolerance in elderly clients with cancer is likely to decrease due to factors such as diminished adaptative capacity, increased physical discomfort, and the psychological impact of the disease. Cancer is known to cause various physical and emotional stressors that can lower the pain threshold, leading to a decrease in pain tolerance. Choices A, C, and D are incorrect because cancer and its associated effects typically result in a decrease in pain tolerance rather than remaining constant, increasing, or having no impact.

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