Nursing Elites

1. The nurse is caring for a client with a chest tube after thoracic surgery. What is the most important assessment related to the chest tube?

• A. Ensure continuous bubbling in the water seal chamber
• B. Measure the amount of drainage every shift
• C. Keep the drainage system at the level of the chest
• D. Assess for subcutaneous emphysema around the insertion site

Correct answer: D

Rationale: The most important assessment related to a chest tube after thoracic surgery is to assess for subcutaneous emphysema around the insertion site. Subcutaneous emphysema can indicate air leakage from the pleural space, which can lead to serious complications such as a pneumothorax. Ensuring continuous bubbling in the water seal chamber is not the most critical assessment as it is a normal finding in a chest drainage system. While measuring the amount of drainage is important to monitor the client's condition, it is not as crucial as assessing for subcutaneous emphysema. Keeping the drainage system at the level of the chest helps maintain proper function but is not the most critical assessment in this scenario.

2. When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include?

• A. Wash hands frequently.
• B. Avoid drinking lake water.
• C. Do not share personal products.
• D. Wear long sleeves and pants.

Correct answer: D

Rationale: The correct answer is 'Wear long sleeves and pants.' This instruction is crucial in reducing the risk of Lyme disease because it helps minimize exposure to ticks that carry the disease. Ticks are commonly found in grassy and wooded areas, so covering up with long sleeves and pants can act as a physical barrier and prevent ticks from attaching to the skin. Choices A, B, and C are not directly related to preventing Lyme disease. Washing hands frequently is important for general hygiene but not specifically for preventing tick bites. Avoiding drinking lake water is more about preventing waterborne illnesses rather than Lyme disease. Not sharing personal products is important for preventing the spread of infections but is not directly related to Lyme disease prevention.

3. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?

• A. Dry mucous membranes
• B. Increased urine output
• C. Tachycardia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.

4. A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)

• A. Raisin bran muffins
• B. Bowl of oatmeal
• C. Cup of raspberries
• D. Scrambled eggs

Correct answer: A

Rationale: A high-fiber diet is beneficial for managing hemorrhoids as it helps maintain bowel regularity. Raisin bran muffins are a good choice for breakfast as they are high in fiber. Oatmeal is also a high-fiber option that aids digestion and prevents constipation. Raspberries are rich in fiber and contribute to a high-fiber diet. Scrambled eggs, on the other hand, are not high in fiber and do not provide the necessary fiber content needed for managing hemorrhoids.

5. The nurse is caring for a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: The correct answer is D, prolonged PT/INR. In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This indicates impaired liver function, leading to a higher risk of bleeding. Elevated AST and ALT (choice A) are indicators of liver damage but do not directly assess the risk of bleeding. Decreased albumin level (choice B) reflects impaired liver function but is not as directly related to bleeding risk as a prolonged PT/INR. Elevated bilirubin level (choice C) is a sign of liver dysfunction, specifically related to bile metabolism, and while important, it is not as directly associated with bleeding risk as a prolonged PT/INR in the context of chronic liver disease.

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