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 client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

• A. Encourage the client to lie down in a quiet room.
• B. Ask the client directly what they are hearing.
• C. Tell the client that the voices are not real.
• D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

3. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 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 correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

4. When caring for a client experiencing delirium, which of the following is essential?

• A. Controlling behavioral symptoms with low-dose psychotropics
• B. Identifying the underlying causative condition or illness
• C. Manipulating the environment to increase orientation
• D. Decreasing or discontinuing all previously prescribed medications

Correct answer: B

Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.

5. A nurse is collecting data from 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 am frustrated that I cannot lift my arm to comb my hair.
• B. I am upset that I can't hold a pencil anymore.
• C. I am embarrassed that I cannot open my milk carton.
• D. I am so frustrated that I cannot even open my milk carton for breakfast.

Correct answer: D

Rationale: The correct answer is D because the inability to perform activities of daily living, such as opening a milk carton, suggests difficulties with fine motor skills. Occupational therapists specialize in helping individuals regain independence in such tasks. Choices A, B, and C do not specifically address fine motor skills related to activities of daily living, therefore not warranting an occupational therapy referral. Choice A mentions lifting the arm, which involves gross motor skills rather than fine motor skills. Choice B involves holding a pencil, which is more related to hand dexterity and strength rather than fine motor skills. Choice C, opening a milk carton, could be related to fine motor skills but is not as clear-cut as the inability described in Choice D, where the frustration is explicitly about the inability to perform a daily living task.

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