Nursing Elites

1. The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?

• A. The chest tube is securely taped at the insertion site.
• B. The water seal chamber is filled to the correct level.
• C. The chest drainage system is below chest level.
• D. There are no air leaks in the system.

Correct answer: C

Rationale: The correct answer is C. The chest drainage system should always be kept below chest level to ensure proper drainage. Having the system above chest level can result in ineffective drainage. Choices A, B, and D are all correct actions to maintain the integrity and functionality of the chest tube system. Securing the chest tube at the insertion site, maintaining the water seal chamber at the correct level, and ensuring there are no air leaks are all essential components of caring for a client with a chest tube post-surgery.

2. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

• A. We will call the health care provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occur.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.

3. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the UAP?

• A. Report any client complaint of pain or discomfort
• B. Weigh the client and report any weight gain
• C. Note and report the client's food and liquid intake during meals and snacks
• D. All of the above

Correct answer: D

Rationale: The UAP can be tasked with reporting complaints, monitoring weight gain, and tracking food and fluid intake, all of which are important in managing a client with Cushing's syndrome. These tasks fall within the UAP's scope of practice. Reporting client complaints helps in early identification of complications, monitoring weight is crucial due to fluid retention in Cushing's syndrome, and tracking food and fluid intake assists in dietary management. Choices A, B, and C are all necessary components of care for a client with Cushing's syndrome, making option D the correct answer.

4. When assessing constipation in elders, what action should be the nurse's priority?

• A. Obtain a complete blood count
• B. Obtain a health and dietary history
• C. Refer to a provider for a physical examination
• D. Measure height and weight

Correct answer: B

Rationale: Obtaining a detailed health and dietary history is crucial when assessing constipation in elders. This helps the nurse identify potential causes such as inadequate fluid intake, low fiber diet, lack of physical activity, or medications that could be contributing to constipation. A complete blood count (Choice A) is not the priority in the initial assessment of constipation. Referring to a provider for a physical examination (Choice C) would be done after gathering more information from the health history. Measuring height and weight (Choice D) is not directly relevant to assessing constipation and identifying its causes.

5. A client with acute pancreatitis is prescribed nothing by mouth (NPO). What should the nurse prioritize in this client's care?

• A. Administer oral pain medication.
• B. Monitor the client's intake and output.
• C. Monitor the client for signs of infection.
• D. Insert a nasogastric tube for decompression.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is prescribed nothing by mouth (NPO), the nurse should prioritize monitoring the client's intake and output. This is crucial for assessing the client's fluid balance and ensuring that they are not becoming dehydrated or developing complications related to fluid status. Option A is incorrect because oral pain medication should not be administered to a client who is NPO. Option C is not the priority at this time, although monitoring for infection is important in the overall care of the client. Option D is not the initial priority unless there are specific indications for decompression, which would be determined by the healthcare provider.

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