Nursing Elites

1. What does continuous bubbling in the chest tube water seal chamber indicate?

• A. An air leak
• B. Normal chest tube function
• C. A blocked chest tube
• D. Continuous drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This occurs when air is entering the system from the outside, preventing the lung from fully re-expanding. Choice B is incorrect because continuous bubbling is not a sign of normal chest tube function. Choice C is incorrect because a blocked chest tube would typically exhibit no bubbling or fluctuation in the water seal chamber. Choice D is incorrect as continuous drainage would not cause bubbling in the water seal chamber.

2. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?

• A. Breath sounds
• B. Temperature
• C. Blood pressure
• D. Creatine kinase

Correct answer: A

Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.

3. A client is being taught about fecal occult blood testing (FOBT) for colorectal cancer screening. Which of the following statements should the nurse include in the teaching?

• A. Your provider will use a stool sample obtained during a digital rectal examination to perform the test.
• B. Your provider will recommend a stimulant laxative before the test to empty the bowel.
• C. You should start annual fecal occult blood testing for colorectal cancer screening at the age of 40.
• D. You should avoid corticosteroids before the test.

Correct answer: D

Rationale: The correct answer is D because the nurse should advise the client to avoid corticosteroids, anti-inflammatory medications, and vitamin C before fecal occult blood testing to prevent false-positive results. Choice A is incorrect as stool samples for FOBT are usually collected using a kit at home. Choice B is incorrect because stimulant laxatives are not typically used before FOBT. Choice C is incorrect as guidelines recommend starting colorectal cancer screening at the age of 50, not 40.

4. What is the primary concern in a patient with a low CD4 T-cell count in HIV?

• A. Increased risk of infection
• B. Increased risk of bleeding
• C. Decreased immunity leading to opportunistic infections
• D. Increased risk of cardiac complications

Correct answer: A

Rationale: The correct answer is A: Increased risk of infection. In HIV patients with a low CD4 T-cell count, the primary concern is the increased susceptibility to infections due to compromised immunity. This compromised immune system can lead to various infections, making infection control crucial. Choice B, increased risk of bleeding, is not directly associated with a low CD4 count in HIV. Option C, decreased immunity leading to opportunistic infections, conveys a similar concern as the correct answer but lacks specificity. Choice D, increased risk of cardiac complications, is not typically the primary concern in HIV patients with a low CD4 count, as infections and opportunistic diseases pose more immediate threats to health.

5. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client's skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder to the client's skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

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