Nursing Elites

1. A client has a right-sided pneumothorax, and a chest tube is inserted. Which finding indicates that the chest drainage system is functioning correctly?

• A. Gentle bubbling in the suction chamber
• B. Crepitus around the insertion site
• C. Constant bubbling in the water seal chamber
• D. Absence of breath sounds on the right side

Correct answer: A

Rationale: In a chest drainage system, gentle bubbling in the suction chamber indicates proper functioning, showing that the system is connected and working effectively to remove air or fluid from the pleural space. Crepitus around the insertion site (Choice B) suggests subcutaneous emphysema, not chest tube functionality. Constant bubbling in the water seal chamber (Choice C) indicates an air leak. Absence of breath sounds on the right side (Choice D) is indicative of the pneumothorax, not the chest tube function.

2. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

• A. Diazepam IV
• B. Lorazepam PO
• C. Diltiazem IV
• D. Clonazepam PO

Correct answer: A

Rationale: In the scenario described, where the client has been experiencing repeated tonic-clonic seizures over an extended period, the priority is to administer a medication that can rapidly terminate the seizures. Diazepam is the medication of choice for status epilepticus due to its rapid onset of action within 10 minutes when administered intravenously. Lorazepam is also an option, but it is typically administered intravenously as well. Diltiazem is a calcium channel blocker used for conditions like hypertension and angina, not for seizures. Clonazepam, although used for seizures, is not the ideal choice in this acute situation due to its slower onset of action compared to benzodiazepines like diazepam and lorazepam.

3. What are the common manifestations of a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Severe headache and confusion
• D. Seizures and convulsions

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. A thrombotic stroke is characterized by a gradual onset of symptoms due to interrupted blood flow in the brain. This interruption results in manifestations such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache, confusion, seizures, and convulsions are more commonly associated with conditions other than thrombotic strokes.

4. A patient with GERD is receiving dietary teaching from a nurse. What should the nurse recommend?

• A. Avoid mint and pepper
• B. Increase fluid intake before meals
• C. Eat three large meals per day
• D. Avoid drinking water with meals

Correct answer: A

Rationale: The correct recommendation for a patient with GERD is to avoid foods like mint and pepper, as these can help reduce gastric acid secretion and alleviate symptoms. Mint and pepper are known to relax the lower esophageal sphincter, leading to increased reflux. Increasing fluid intake before meals (choice B) may worsen GERD symptoms by distending the stomach. Eating three large meals per day (choice C) can also aggravate GERD because large meals can lead to increased gastric pressure and reflux. Avoiding drinking water with meals (choice D) is generally recommended for GERD; however, the most crucial advice in this case is to avoid mint and pepper for better symptom management.

5. What are the dietary recommendations for a patient with GERD?

• A. Avoid mint and spicy foods
• B. Eat large meals before bedtime
• C. Consume liquids with meals
• D. Avoid NSAIDs

Correct answer: A

Rationale: The correct answer is to avoid mint and spicy foods for a patient with GERD. These foods can increase gastric acid secretion and worsen symptoms of GERD. Choice B is incorrect because eating large meals before bedtime can exacerbate GERD symptoms due to increased gastric pressure when lying down. Choice C is also incorrect as consuming liquids with meals can lead to increased gastric distention, potentially triggering GERD symptoms. Choice D, avoiding NSAIDs, though important for some patients with GERD due to their potential to irritate the stomach lining, is not a general dietary recommendation for all GERD patients.

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