Nursing Elites

1. The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?

• A. Increase the setting on the suction.
• B. Notify the provider immediately.
• C. Re-position the chest tube.
• D. Take the tubing apart to assess for clots.

Correct answer: B

Rationale: If the drainage from the chest tube decreases significantly, it may indicate a blockage by a clot, potentially leading to cardiac tamponade. The nurse's priority action should be to notify the healthcare provider immediately for further evaluation and intervention. Increasing suction, re-positioning the chest tube, or disassembling the tubing independently are not appropriate actions without healthcare provider guidance in this situation.

2. A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?

• A. Administer pain medication as ordered.
• B. Check the client's blood pressure.
• C. Place the client in a supine position.
• D. Increase the client's fluid intake.

Correct answer: B

Rationale: The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.

3. A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I can sleep on my side as long as I use a pillow between my legs.
• C. I will avoid bending at the waist to pick things up.
• D. I can bend down to tie my shoes after 2 weeks.

Correct answer: D

Rationale: After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.

4. A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?

• A. The importance of regular exercise
• B. Proper administration of insulin
• C. Maintaining a low-carbohydrate diet
• D. Recognizing signs of hyperglycemia

Correct answer: B

Rationale: Proper administration of insulin is crucial for clients with type 1 diabetes as they are dependent on insulin for blood glucose control.

5. When preparing a client for transfer to the ICU for placement of a pulmonary artery catheter, the nurse should explain that this catheter is used to monitor which of the following conditions?

• A. Intracranial pressure
• B. Spinal cord perfusion
• C. Renal function
• D. Hemodynamic status

Correct answer: D

Rationale: A pulmonary artery catheter is primarily used to monitor hemodynamic status. It provides essential information on cardiac output, preload, afterload, and overall cardiovascular function. This data helps healthcare providers manage the client's fluid status, cardiac function, and guide treatment interventions in critically ill patients. Monitoring intracranial pressure, spinal cord perfusion, or renal function would require different monitoring devices and techniques, not a pulmonary artery catheter.

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