Nursing Elites

1. What is the priority for the nurse when caring for a patient with a chest tube?

• A. Ensure tube patency and observe for air leaks
• B. Maintain sterile technique during dressing changes
• C. Monitor drainage and record output
• D. Observe for signs of infection and monitor for subcutaneous emphysema

Correct answer: A

Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.

2. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?

• A. Use a separate washcloth for the child
• B. Apply cold compresses to the eyes
• C. Apply warm compresses to the eyes
• D. Keep the child home until symptoms have resolved

Correct answer: A

Rationale: The correct answer is to use a separate washcloth for the child. This is important to prevent the spread of infection when a child has conjunctivitis. Using the same washcloth can lead to cross-contamination and further spread of the condition. Applying cold or warm compresses may provide comfort but do not address the prevention of spreading the infection. Keeping the child home until symptoms have resolved may be necessary, but the primary focus should be on preventing the spread of the infection within the household.

3. A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?

• A. Provide teaching to the parents
• B. Report suspected abuse to the appropriate agency
• C. Document the injuries and monitor the child
• D. Counsel the parents privately

Correct answer: B

Rationale: In cases where a child's injuries are inconsistent with the parent's stated cause, it raises concerns about possible abuse. The correct action for the nurse in this situation is to report suspected abuse to the appropriate agency. This is a legal and ethical obligation for healthcare professionals when they suspect child abuse. Providing teaching to the parents (Choice A) may not address the immediate safety concerns of the child. Documenting the injuries and monitoring the child (Choice C) is important but reporting suspected abuse takes precedence to ensure the child's safety. Counseling the parents privately (Choice D) may not be effective if abuse is suspected, as the primary focus should be on protecting the child.

4. What is the proper technique for obtaining a blood specimen from a central venous line?

• A. Use sterile gloves and discard the first 10 mL of blood
• B. Flush the line with heparin and then draw the specimen
• C. Draw the specimen and then administer heparin
• D. Use non-sterile gloves to reduce contamination risk

Correct answer: A

Rationale: The correct technique for obtaining a blood specimen from a central venous line is to use sterile gloves and discard the first 10 mL of blood. This practice helps ensure that the blood sample collected is not contaminated. Choice B is incorrect because flushing the line with heparin before drawing the specimen can contaminate the sample. Choice C is incorrect as administering heparin before drawing the specimen can affect the accuracy of the blood sample. Choice D is incorrect as using non-sterile gloves increases the risk of contamination, which is not recommended when obtaining a blood specimen from a central venous line.

5. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

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