Nursing Elites

1. Which of the following food selections would need to be removed from a tray for a client recovering from thyroidectomy?

• A. Fresh apple
• B. V8 juice
• C. Mustard greens
• D. Ice cream

Correct answer: A

Rationale: The correct answer is a fresh apple. After a thyroidectomy, it is important to avoid hard and crunchy foods like apples due to the proximity of the esophagus to the surgical site. Apples can be difficult to chew and swallow, posing a risk of injury or discomfort to the patient. V8 juice, mustard greens, and ice cream are softer options that would be more suitable for a client recovering from thyroidectomy.

2. Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?

• A. Ca
• B. K
• C. Na
• D. Cl

Correct answer: B

Rationale: The correct answer is 'K.' Normal serum potassium levels range between 3.5 and 5.5 mEq/L. Mr. Smith's potassium level of 2.0 mEq/L is significantly below the normal range, indicating hypokalemia, which can lead to serious risks such as cardiac arrhythmias. The levels of sodium (Na), calcium (Ca), and chloride (Cl) are within normal ranges, so they do not pose an immediate risk to the client's health. Therefore, the nurse should report the low potassium level to the physician for prompt intervention.

3. The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

• A. Muscle tetany
• B. Syncope
• C. Numbness
• D. Anxiety

Correct answer: D

Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.

4. The charge nurse is observing a student nurse caring for a 4-month-old infant in isolation diagnosed with RSV. Which of the following would indicate to the charge nurse that the student nurse needs further instruction on isolation standards?

• A. Donning clean gloves each time she goes in the room.
• B. Wearing a clean mask each time she goes in the room.
• C. Labeling the door so staff will use Airborne Precautions.
• D. Wearing a gown when she goes in the room to administer medication.

Correct answer: A

Rationale: The correct answer is 'Donning clean gloves each time she goes in the room.' Sterile gloves are not necessary for standard isolation precautions; clean gloves are sufficient. The student nurse should be instructed to use clean gloves to reduce the risk of spreading infections. Wearing a clean mask each time she goes in the room is a good practice to prevent the spread of respiratory infections like RSV. Labeling the door for Airborne Precautions is appropriate for RSV. Wearing a gown when entering the room to administer medication helps prevent the transmission of infectious agents.

5. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:

• A. Remove air from the pleural space
• B. Create access for irrigating the chest cavity
• C. Evacuate secretions from the bronchioles and alveoli
• D. Drain blood and fluid from the pleural space

Correct answer: A

Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.

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