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. An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the nurse document as evidence that the amount of insulin is inadequate?

• A. States that her feet are constantly cold and numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dL
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: The correct answer is C. Consistently high evening glucose levels indicate that the current insulin dosage is inadequate to maintain proper glucose control. Choice A is incorrect because cold and numb feet are more indicative of peripheral vascular disease rather than inadequate insulin dosage. Choice B describes a wound that may be related to poor circulation or neuropathy but not necessarily inadequate insulin dosage. Choice D suggests gastrointestinal issues that are not directly related to insulin dosage adequacy.

3. The nurse observes a UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the nurse take?

• A. Stop the procedure and tell the UAP to place the client in a Fowler's position
• B. Praise the UAP for doing the oral hygiene but encourage family participation
• C. Tell the UAP to continue because the unconscious client is positioned safely
• D. Enroll the UAP in a hospital education class on conducting safe client care

Correct answer: C

Rationale: The correct answer is to tell the UAP to continue because the unconscious client is positioned safely for oral care. Placing an unconscious client in a side-lying position helps prevent aspiration, and having an emesis basin under the chin is appropriate to catch any fluids. Therefore, the nurse should acknowledge that the UAP is performing the procedure correctly. Choices A, B, and D are incorrect. Placing the client in a Fowler's position is not necessary for this procedure as the client is already positioned safely. Praise and encouragement for family participation are important aspects but not the immediate action needed in this scenario. Enrolling the UAP in a hospital education class is not warranted as the current procedure is being performed correctly.

4. A nurse is completing a focused assessment of an older adult's skin. The nurse notes a crusted 0.7 cm lesion on the client's forehead. Which action should the nurse take in response to this finding?

• A. Report the finding to the healthcare provider
• B. Place a clear occlusive dressing over the site
• C. Apply a warm compress to remove the crusted area
• D. Explain that this is a normal skin change with aging

Correct answer: A

Rationale: A crusted lesion, especially in an older adult, could be indicative of skin cancer or another serious condition. Therefore, reporting this finding to the healthcare provider is crucial for further evaluation and appropriate management. Placing an occlusive dressing (Choice B) could prevent proper assessment and treatment. Applying a warm compress (Choice C) may not be suitable for a suspicious skin lesion as it could worsen the condition. Explaining it as a normal skin change (Choice D) without proper evaluation can delay necessary interventions and potentially harm the patient.

5. What disorder closely matches Suzy's symptoms?

• A. Antisocial personality disorder
• B. Borderline personality disorder
• C. Schizoid personality disorder
• D. Dissociative Identity Disorder

Correct answer: B

Rationale: Suzy's symptoms are characteristic of Borderline Personality Disorder (BPD). BPD includes instability in relationships, self-image, and emotions, as well as impulsivity and self-harm. Choice A, Antisocial personality disorder, is characterized by a disregard for others' rights and lack of empathy, which does not align with Suzy's symptoms. Schizoid personality disorder, choice C, is characterized by a lack of interest in social relationships, which is not a prominent feature in Suzy's case. Dissociative Identity Disorder, choice D, involves the presence of two or more distinct identities or personality states, which is not reflected in Suzy's symptoms.

Similar Questions