Nursing Elites

1. What is the priority when managing a client with a chest tube postoperatively?

• A. Clamp the chest tube for 30 minutes every 4 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.

2. What are the common causes of postoperative pain and how should it be managed?

• A. Surgical incision and muscle tension
• B. Nerve damage and wound complications
• C. Hypotension and respiratory issues
• D. Infection at the incision site

Correct answer: A

Rationale: Postoperative pain is commonly caused by the surgical incision and muscle tension. The correct answer is A. Surgical incisions cause tissue damage, triggering pain responses. Muscle tension can result from factors like positioning during surgery or guarding due to pain. Managing postoperative pain caused by surgical incisions and muscle tension involves the use of analgesics to alleviate discomfort. Choices B, C, and D are incorrect. Nerve damage and wound complications may also cause pain but are not as common as surgical incisions and muscle tension. Hypotension and respiratory issues are not direct causes of postoperative pain. Infection at the incision site can lead to pain, but it is a specific complication rather than a common cause of postoperative pain.

3. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

• A. Increase in frequency of swallowing.
• B. Moderate sanguineous drainage on the drip pad.
• C. Bruising to the face.
• D. Absent gag reflex.

Correct answer: A

Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.

4. What are the nursing priorities for a patient experiencing an asthma exacerbation?

• A. Administer a bronchodilator
• B. Encourage deep breathing
• C. Provide oxygen therapy
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.

5. A nurse is caring for a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I can't brush my teeth properly
• B. I am so frustrated I can't open my milk carton
• C. I can't hold a pencil
• D. I can't write anymore

Correct answer: B

Rationale: The correct answer is B. The client's frustration with opening a milk carton indicates difficulty with activities of daily living, which is a common concern addressed by occupational therapists. Choices A, C, and D are related to fine motor skills, which may also be addressed by an occupational therapist but are not as directly linked to activities of daily living as struggling with tasks like opening containers.

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