Nursing Elites

1. Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.

2. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?

• A. Accept and document the client's wish to refrain from bathing.
• B. Offer to give the client a bed bath, avoiding the perineal area.
• C. Obtain written brochures about menstruation to give to the client.
• D. Teach the importance of personal hygiene during menstruation to the client.

Correct answer: D

Rationale: The priority for the nurse is to educate the client on the importance of personal hygiene during menstruation. Although it's crucial to respect the client's beliefs, providing education ensures the client receives accurate information to make informed decisions about her hygiene practices. By offering teaching first, the nurse can address any misconceptions or concerns the client may have while promoting optimal hygiene practices for overall well-being. Choice A should not be the first action as it does not address the client's potential misinformation about hygiene. Choice B is not ideal as it only offers a temporary solution without addressing the underlying issue. Choice C is not the priority as the immediate concern is the client's personal hygiene practices.

3. What action should be taken when adding sterile liquids to a sterile field?

• A. Use an expired sterile liquid if the bottle is sealed and unopened.
• B. Consider the sterile field contaminated if it becomes wet during the procedure.
• C. Remove the container cap and place it with the inside facing up on the sterile field.
• D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

4. The client has a chest tube. What is the most important action for the nurse to take?

• A. Ensure the chest tube remains unclamped at all times.
• B. Empty the chest tube every 2 hours.
• C. Keep the drainage system below the level of the chest.
• D. Assess for subcutaneous emphysema.

Correct answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

5. During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?

• A. Assign an unlicensed assistive personnel to transport the client via a wheelchair.
• B. Remind the client to walk carefully down the stairs until reaching a lower floor.
• C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
• D. Open the closest fire doors to facilitate the evacuation of ambulatory clients.

Correct answer: B

Rationale: During a fire evacuation, it is crucial for ambulatory clients to be reminded to walk carefully down the stairs. This helps ensure the safety of the client by preventing falls or injuries during the evacuation process. Directing the client to proceed cautiously down the stairs until reaching a lower floor provides necessary guidance to promote a safe evacuation process. Choice A is incorrect because assigning unlicensed assistive personnel to transport the client via a wheelchair may delay the evacuation process and increase the risk of injury. Choice C is incorrect as it distracts the ambulatory client from evacuating safely by involving them in assisting another client. Choice D is incorrect as opening fire doors may not be the most appropriate action at that moment; prioritizing safe evacuation procedures for ambulatory clients is essential.

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