Nursing Elites

1. When caring for a patient with a chest tube, which nursing action is most important?

• A. Clamping the chest tube every 2 hours to prevent air leaks
• B. Keeping the drainage system below chest level
• C. Emptying the drainage system every hour to prevent backflow
• D. Removing the chest tube when drainage decreases significantly

Correct answer: B

Rationale: The most crucial nursing action when caring for a patient with a chest tube is to keep the drainage system below chest level (choice B). This position helps ensure proper drainage and prevents backflow of fluid or air into the pleural space, promoting optimal functioning of the chest tube. Clamping the chest tube every 2 hours (choice A) is incorrect as it can obstruct the drainage system and lead to complications. Emptying the drainage system every hour (choice C) is unnecessary unless there are specific clinical indications. Removing the chest tube when drainage decreases significantly (choice D) is also incorrect as the decision should be based on overall clinical assessment rather than drainage amount alone.

2. What is an essential nursing action before administering a blood transfusion?

• A. Checking the patient’s blood pressure
• B. Verifying the blood type and patient identity with another nurse
• C. Flushing the IV line with saline
• D. Administering pre-transfusion medications

Correct answer: B

Rationale: Verifying the blood type and patient identity with another nurse is crucial before administering a blood transfusion. This step helps prevent transfusion reactions and ensures that the correct blood is given to the right patient. Checking the patient’s blood pressure, although important, is not directly related to verifying blood type and patient identity. Flushing the IV line with saline is a good practice but is not as critical as confirming the blood type and patient identity. Administering pre-transfusion medications would come after verifying the blood type and patient identity.

3. Which task could the nurse safely delegate to the UAP?

• A. Oral feeding of a two-year-old child after application of a hip spica cast
• B. Assessment of the placement and patency of an NG tube
• C. Participation in staff rounds to record notes regarding client goals
• D. Evaluation of a client's incisional pain following narcotic administration

Correct answer: A

Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.

4. Which vitamin deficiency is most associated with night blindness?

• A. Vitamin A
• B. Vitamin B12
• C. Vitamin C
• D. Vitamin D

Correct answer: A

Rationale: The correct answer is Vitamin A. Vitamin A deficiency leads to night blindness because this vitamin is crucial for the formation of rhodopsin, a photopigment in the retina. Rhodopsin is essential for vision in low-light conditions. Vitamin B12 deficiency can lead to anemia and neurological issues but is not directly related to night blindness. Vitamin C deficiency can cause scurvy, affecting connective tissues, but not night vision. Vitamin D deficiency can lead to bone disorders but is not primarily associated with night blindness.

5. What is the priority intervention for a patient experiencing an acute asthma attack?

• A. Administering a bronchodilator
• B. Encouraging the patient to drink fluids
• C. Applying a high-flow oxygen mask
• D. Performing chest physiotherapy

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention in an acute asthma attack. Bronchodilators help to quickly open the airways, relieve bronchospasm, and improve breathing. Encouraging the patient to drink fluids may be beneficial for other conditions but is not the priority in an acute asthma attack. Applying a high-flow oxygen mask may be necessary in severe cases of respiratory distress but is not the initial priority when managing an acute asthma attack. Performing chest physiotherapy is not indicated as the primary intervention for an acute asthma attack and may not address the immediate need to open the airways and improve breathing.

Similar Questions