Nursing Elites

1. The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Subcutaneous emphysema
• C. Crepitus around the insertion site
• D. Drainage of 50 ml per hour

Correct answer: B

Rationale: Subcutaneous emphysema is the correct answer as it is most concerning in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, requiring immediate intervention to prevent complications. Oxygen saturation of 94% is acceptable and does not require immediate intervention. Crepitus around the insertion site may be a normal finding after chest tube placement and does not necessarily indicate a complication. Drainage of 50 ml per hour is within the expected range for a chest tube and does not require immediate intervention.

2. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?

• A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
• B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
• C. Push the undiluted dextrose slowly through the current IV infusion.
• D. Ask the pharmacist to add the dextrose to a TPN solution.

Correct answer: C

Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.

3. A client with urticaria due to environmental allergies is taking diphenhydramine. Which complaint should the nurse identify as a side effect of the OTC medication?

• A. Nausea and indigestion.
• B. Hypersalivation.
• C. Eyelid and facial twitching.
• D. Increased appetite.

Correct answer: A

Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. This medication can have anticholinergic effects, leading to these symptoms. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.

4. A client with a tracheostomy is experiencing thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Encourage fluid intake to thin secretions.
• B. Administer a mucolytic agent.
• C. Increase humidity in the client's room.
• D. Perform deep suctioning as needed.

Correct answer: C

Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.

5. The nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
• B. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain.
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

Correct answer: D

Rationale: The correct answer is D. A client who had an abdominal-perineal resection 2 days ago with no drainage on the dressing but is presenting with fever and chills requires immediate attention. This presentation raises concerns for peritonitis, a serious complication that necessitates prompt assessment and intervention to prevent further complications. Choices A, B, and C do not indicate an immediate risk for a life-threatening condition like peritonitis, making them lower priority compared to choice D.

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