Nursing Elites

1. When caring for a client with a chest tube, which intervention is most important?

• A. Keep the drainage system at chest level.
• B. Ensure that the chest tube is clamped at all times.
• C. Strip the chest tube every shift.
• D. Ensure that the chest tube is connected to a water-seal drainage system.

Correct answer: D

Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.

2. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?

• A. Oliguria.
• B. Kussmaul respirations.
• C. Fruity odor on the breath.
• D. Blood glucose level of 250 mg/dL.

Correct answer: B

Rationale: Kussmaul respirations (B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DKA) and are expected in this condition. While oliguria (A), fruity odor on the breath (C), and elevated blood glucose level (D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.

3. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

4. While observing an unlicensed assistive personnel (UAP) providing a total bed bath for a confused and lethargic client, the nurse notes the UAP soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take?

• A. Remove the basin of water from the client’s bed immediately
• B. Remind the UAP to dry between the client’s toes completely
• C. Advise the UAP that this procedure may lead to skin damage
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to remind the unlicensed assistive personnel (UAP) to dry between the client’s toes completely. Failing to dry between the toes can lead to skin breakdown due to excessive moisture accumulation. Proper drying is essential to maintain skin integrity and prevent complications in the client's care. Removing the basin of water immediately may disrupt the care process and not address the root cause of the issue. Advising about potential skin damage is not as direct and actionable as reminding to dry between the toes. Adding skin cream to the water may not be appropriate without specific orders and can potentially worsen the situation by increasing moisture.

5. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

• A. Suction deeper to remove secretions.
• B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
• C. Remove the suction as quickly as possible.
• D. Insert and remove the suction multiple times to clear secretions.

Correct answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.

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