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. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

3. What is the proper technique for measuring blood pressure manually?

• A. Use a stethoscope to listen for the Korotkoff sounds
• B. Ensure the patient is seated with the arm supported
• C. Use a manual sphygmomanometer
• D. Deflate the cuff slowly while listening to the heartbeat

Correct answer: A

Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.

4. A nurse is teaching a client who has hypertension about dietary modifications. Which of the following instructions should the nurse include?

• A. Increase sodium intake
• B. Reduce sodium intake to less than 1,500 mg per day
• C. Limit caffeine intake
• D. Increase caffeine intake to improve focus

Correct answer: B

Rationale: The correct answer is B: 'Reduce sodium intake to less than 1,500 mg per day.' For clients with hypertension, reducing sodium intake is crucial as it helps manage blood pressure. High sodium intake can lead to fluid retention and increased blood pressure. Choice A is incorrect because increasing sodium intake would worsen hypertension. Choice C is also correct as limiting caffeine intake is beneficial for managing hypertension. Choice D is incorrect as increasing caffeine intake can elevate blood pressure, which is detrimental for clients with hypertension.

5. A healthcare provider is reviewing the medical record of a client who is scheduled for an abdominal paracentesis. Which of the following actions should the healthcare provider take to prepare the client for this procedure?

• A. Assist the client to void
• B. Instruct the client to hold their breath
• C. Place the client in a lateral recumbent position
• D. Prepare to administer a sedative

Correct answer: A

Rationale: Assisting the client to void before a paracentesis is essential to reduce the risk of bladder injury during the procedure. Voiding helps empty the bladder, preventing accidental puncture during the insertion of the needle. Instructing the client to hold their breath is incorrect and can increase the risk of complications. Placing the client in a lateral recumbent position is not directly related to bladder safety during a paracentesis. Preparing to administer a sedative is not a standard preparation for this procedure and is not aimed at preventing bladder injury.

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