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. What is the appropriate intervention for fluid overload?

• A. Restrict fluid intake
• B. Administer diuretics
• C. Monitor vital signs
• D. All of the above

Correct answer: D

Rationale: The appropriate intervention for fluid overload involves a combination of measures, including restricting fluid intake to prevent further fluid accumulation, administering diuretics to help the body eliminate excess fluids, and closely monitoring vital signs to assess the patient's response to treatment. Therefore, all of the above options are correct. Restricting fluid intake alone may not be sufficient to address existing fluid overload without additional measures like diuretic therapy. Monitoring vital signs is essential to evaluate the effectiveness of the interventions and the patient's overall condition.

3. A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.

4. Which of the following is an early indicator that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Hypotension
• C. Irritability
• D. Confusion

Correct answer: C

Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.

5. A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?

• A. It's a living will outlining your funeral wishes
• B. It's a document that allows you to donate organs
• C. It includes end-of-life care instructions
• D. It provides legal guardianship rights

Correct answer: C

Rationale: The correct response is C: 'It includes end-of-life care instructions.' An advance directive is a legal document that outlines a client's preferences for medical treatment and end-of-life care in case they are unable to communicate. Choice A is incorrect because an advance directive focuses on healthcare decisions, not funeral arrangements. Choice B is incorrect as organ donation is a separate process from advance directives. Choice D is incorrect as advance directives do not provide legal guardianship rights, but rather specify healthcare wishes.

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