Nursing Elites

1. The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

• A. Fluctuation of the fluid level within the water seal chamber
• B. Absence of fluid in the drainage tubing
• C. Continuous bubbling within the water seal chamber
• D. Equal amounts of fluid drainage in each collection chamber

Correct answer: A

Rationale: Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.

2. A client is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select ONE that does not apply)

• A. Find an activity that you enjoy and will keep your hands busy.
• B. Make a list of reasons you want to stop smoking.
• C. Identify a punishment for yourself in case you backslide.
• D. Drink at least eight glasses of water each day.

Correct answer: D

Rationale: When educating a client on smoking cessation, the nurse should include several strategies. Finding an activity to keep hands busy helps distract from smoking urges. Making a list of reasons to quit smoking reinforces motivation. Identifying a consequence for backsliding can serve as a deterrent. Drinking water is beneficial for overall health but is not directly related to smoking cessation. It's crucial to support the client, encourage healthy habits, and address challenges without punitive measures.

3. A patient is receiving discharge instructions after experiencing a stroke. Which instruction is most important for preventing another stroke?

• A. Take prescribed antihypertensive medications regularly.
• B. Engage in physical therapy exercises.
• C. Follow a low-fat, low-cholesterol diet.
• D. Attend regular follow-up appointments with the healthcare provider.

Correct answer: A

Rationale: The correct answer is to take prescribed antihypertensive medications regularly. Hypertension is a major risk factor for stroke, and controlling blood pressure through medication is crucial in preventing recurrent strokes. While physical therapy, diet, and follow-up appointments are also important aspects of post-stroke care, managing hypertension with medication takes precedence due to its direct impact on stroke prevention.

4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

• A. Elevate the head of the client's bed.
• B. Measure and compare cuff pressures.
• C. Place the client on NPO status.
• D. Request a swallow study for the client.

Correct answer: B

Rationale: When food particles are noted during suctioning of a client with a tracheostomy tube, it can indicate tracheomalacia due to constant pressure from the tracheostomy cuff. This condition may lead to dilation of the tracheal passage. To address this issue, the nurse should measure and compare cuff pressures. By monitoring these pressures and comparing them to previous readings, the nurse can identify trends and potential complications. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not directly address the cuff pressure issue causing food particles in the secretions.

5. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply)

• A. I held the client's morning bronchodilator medication.
• B. The client is ready to go down to radiology for this examination.
• C. Physical therapy states the client can run on a treadmill.
• D. I advised the client not to smoke for 6 hours prior to the test.

Correct answer: B

Rationale: Communication between the nurse and respiratory therapist is crucial before pulmonary function tests (PFTs). It is important to inform the respiratory therapist that the client is ready for the examination. The nurse should not administer bronchodilator medication before the test as it may affect the results, and the client should not smoke for 6 to 8 hours prior to the test to ensure accurate results. Additionally, PFTs do not involve running on a treadmill; instead, the client may be required to perform specific breathing maneuvers as instructed by the respiratory therapist.

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