Nursing Elites

1. The healthcare provider is caring for a client with a chest tube following thoracic surgery. Which intervention should the healthcare provider include in the plan of care?

• A. Clamp the chest tube for 30 minutes every 2 hours.
• B. Milk the chest tube to ensure patency.
• C. Keep the drainage system at the level of the chest.
• D. Ensure that the chest tube is not clamped or kinked.

Correct answer: D

Rationale: Ensuring that the chest tube is not clamped or kinked is essential to maintain proper drainage and prevent complications. Clamping the chest tube can lead to a buildup of pressure in the pleural space, causing potential harm to the client. Milking the chest tube is not recommended as it can cause damage to the delicate tubing. Keeping the drainage system at the level of the chest ensures proper drainage by gravity, preventing backflow of fluids, but ensuring the tube is not clamped or kinked takes precedence in this scenario.

2. When documenting assessment data, which statement should the nurse record in the narrative nursing notes?

• A. Client appears anxious.
• B. Client's skin is warm and dry.
• C. S1 murmur auscultated in supine position.
• D. Client is resting quietly.

Correct answer: C

Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.

3. A community health nurse is planning a program to reduce the incidence of heart disease in the community. Which intervention should the nurse prioritize?

• A. Distributing educational materials on heart-healthy diets
• B. Organizing free cholesterol screenings
• C. Holding workshops on stress management
• D. Partnering with local gyms to offer fitness classes

Correct answer: B

Rationale: The correct answer is B: Organizing free cholesterol screenings. This intervention is crucial because it helps identify individuals at risk for heart disease by assessing their cholesterol levels. High cholesterol is a significant risk factor for heart disease, and identifying it early can lead to timely interventions and medical care. Choices A, C, and D, while beneficial for overall health, may not directly address the specific risk factor of high cholesterol associated with heart disease. Distributing educational materials on heart-healthy diets (A) could be helpful in preventing heart disease, but identifying individuals already at risk is a more urgent need. Holding workshops on stress management (C) and partnering with local gyms for fitness classes (D) are important for overall health promotion but may not target the specific risk factor of high cholesterol as directly as organizing cholesterol screenings.

4. The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?

• A. Blood pressure of 160/90 mm Hg.
• B. Blood glucose level of 180 mg/dL.
• C. Difficulty speaking.
• D. Temperature of 99.8°F (37.7°C).

Correct answer: C

Rationale: Difficulty speaking is a classic symptom of a stroke, indicating a potential blockage of blood flow to the brain. Immediate intervention is crucial to minimize brain damage. While an elevated blood pressure (Choice A) may need management, it is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) falls within the normal range and is not a critical finding in this context.

5. Following a blizzard that resulted in millions of dollars of damage, the community health nurse is planning to seek financial assistance for families affected by the disaster. Which contact is most important for the nurse to make?

• A. the governor's disaster relief program
• B. Federal Emergency Management Agency (FEMA)
• C. local churches that can provide shelter
• D. the community to seek volunteer contributions

Correct answer: B

Rationale: The correct answer is B, the Federal Emergency Management Agency (FEMA). FEMA is the primary agency responsible for providing financial assistance and support during disasters. While the governor's disaster relief program may also offer help, FEMA has more extensive resources and expertise in disaster response. Local churches providing shelter and seeking volunteer contributions from the community are valuable resources but may not offer the comprehensive financial assistance that FEMA can provide in such situations.

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