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. All of the following are causes of vaginal bleeding in late pregnancy except:

• A. Placenta previa.
• B. Eclampsia.
• C. Abruptio placentae.
• D. Uterine rupture.

Correct answer: B

Rationale: The correct answer is B: Eclampsia. Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizures and/or coma but does not typically present with vaginal bleeding. Choices A, C, and D are abnormal conditions that can cause bleeding, particularly in the third trimester. Placenta previa (choice A) is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. Abruptio placentae (choice C) is the premature separation of the placenta from the uterine wall, causing vaginal bleeding. Uterine rupture (choice D) is a serious obstetrical emergency where the uterus tears during pregnancy or childbirth, resulting in severe bleeding.

3. Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?

• A. Native American
• B. Asian-Pacific
• C. Norwegian
• D. Hispanic

Correct answer: D

Rationale: The correct answer is 'Hispanic.' Hispanic individuals in the United States are at a higher risk for pesticide-related injuries due to their representation among migrant workers in agricultural settings. This exposure to pesticides in their work environments increases their risk compared to other ethnic groups. Choice A, 'Native American,' although indigenous populations may face environmental health disparities, the higher risk in this context is among Hispanic individuals. Choice B, 'Asian-Pacific,' and Choice C, 'Norwegian,' do not have the same level of exposure to pesticides as Hispanic migrant workers, making them less susceptible to pesticide-related injuries.

4. In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?

• A. Place extra padding under the mother to absorb blood from the delivery.
• B. Cut the umbilical cord using sterile scissors.
• C. Suction the baby's mouth and nose.
• D. Wrap the baby in a clean blanket to preserve warmth.

Correct answer: C

Rationale: In an obstetrical emergency, the immediate priority after the baby delivers is to clear the baby's airway by suctioning the mouth and nose to ensure effective breathing. This action helps prevent potential complications like meconium aspiration. Cutting the umbilical cord, wrapping the baby in a blanket, or placing extra padding under the mother can follow once the baby's airway is clear. Therefore, suctioning the baby's mouth and nose is the most critical and time-sensitive intervention in this scenario. Placing extra padding under the mother is not the immediate priority as ensuring the baby's airway is clear. Cutting the umbilical cord and wrapping the baby in a clean blanket are important but can wait until after ensuring the baby's breathing is not compromised.

5. What should a client room environment include?

• A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
• B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
• C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
• D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)

Correct answer: B

Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.

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