Nursing Elites

1. The nurse is caring for a client with a chest tube. Which of these assessments is a priority?

• A. Assessing for subcutaneous emphysema
• B. Assessing for signs of infection at the insertion site
• C. Monitoring the client's respiratory status
• D. Checking the chest tube for kinks or occlusions

Correct answer: B

Rationale: Assessing for signs of infection at the insertion site is the priority when caring for a client with a chest tube. Infection at the insertion site can lead to serious complications such as empyema or sepsis. Monitoring respiratory status is essential but assessing for infection takes precedence to prevent immediate harm. Assessing for subcutaneous emphysema is important but not the priority unless it compromises respiratory function. Checking the chest tube for kinks or occlusions is crucial for proper drainage but is not the priority when infection is a concern.

2. A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 90 beats per minute
• B. A blood pressure of 120/80 mm Hg
• C. A respiratory rate of 16 breaths per minute
• D. A temperature of 98.6 degrees Fahrenheit

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.

3. A client is being treated for tuberculosis (TB). Which of these statements indicates the client understands the transmission of TB?

• A. I need to wear a mask when I go out in public to prevent spreading the infection.
• B. I need to take my medication as prescribed to prevent spreading the infection to others.
• C. I need to cover my mouth when I cough to prevent spreading the infection.
• D. I need to isolate myself from others until my treatment is complete to prevent spreading the infection.

Correct answer: A

Rationale: The correct answer is A because wearing a mask in public can help prevent the spread of TB to others. Choice B is incorrect as taking medication as prescribed helps in treating the infection within the individual but does not directly prevent spreading it to others. Choice C is important for respiratory hygiene but may not be sufficient to prevent transmission. Choice D, isolation until treatment is complete, is crucial for preventing the spread but is not specifically about understanding transmission.

4. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares the elimination of which element?

• A. Sodium
• B. Potassium
• C. Phosphate
• D. Albumin

Correct answer: B

Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps retain potassium while eliminating sodium. This is beneficial for patients with cirrhosis and ascites as they are at risk of low potassium levels. Choice A, Sodium, is incorrect as Spironolactone does not spare the elimination of sodium but rather helps eliminate it. Choice C, Phosphate, is incorrect as Spironolactone does not directly affect phosphate levels. Choice D, Albumin, is incorrect as Spironolactone does not spare the elimination of albumin.

5. The healthcare provider should recognize which of the following as an indication of dehydration in an elderly client?

• A. Skin turgor
• B. Dry mucous membranes
• C. Elevated temperature
• D. Increased pulse pressure

Correct answer: B

Rationale: Dry mucous membranes are a classic sign of dehydration, especially in elderly individuals. Dehydration can lead to decreased moisture in the mucous membranes, making them dry. Skin turgor, although commonly assessed for dehydration in younger individuals, may be less reliable in the elderly due to changes in skin elasticity. Elevated temperature is more indicative of an infection or other conditions. Increased pulse pressure is not typically associated with dehydration in the elderly.

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