Nursing Elites

1. A patient is admitted with an air leak in a chest tube system. What action should the nurse take?

• A. Tighten the connections of the chest tube system
• B. Continue monitoring the patient
• C. Replace the chest tube system
• D. Clamp the chest tube

Correct answer: A

Rationale: When caring for a patient with an air leak in the chest tube system, the nurse should tighten the connections of the chest tube system. This action can help resolve the air leak by ensuring there are no loose connections or leaks in the system. Continuing to monitor the patient (Choice B) is important, but addressing the air leak is a priority. Replacing the chest tube system (Choice C) may not be necessary if tightening the connections resolves the issue. Clamping the chest tube (Choice D) is not appropriate as it can lead to tension pneumothorax.

2. What are the expected symptoms in a patient experiencing a thrombotic stroke?

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

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' Thrombotic strokes typically result in a gradual onset of symptoms due to a blockage in a blood vessel in the brain, leading to a slow progression of neurological deficits. Choices B, C, and D are incorrect because sudden loss of consciousness, seizures, convulsions, severe headache, and vomiting are more commonly associated with other types of strokes or medical conditions, such as hemorrhagic strokes, epilepsy, or migraines.

3. What is an escharotomy and when is it performed?

• A. A surgical incision to release pressure in burn injuries
• B. A procedure to remove dead tissue from wounds
• C. An incision to improve circulation in tight skin after burns
• D. A procedure to remove excess fluid from the chest

Correct answer: A

Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.

4. What is the preferred treatment for a patient with unstable angina admitted with chest pain?

• A. Administer sublingual nitroglycerin
• B. Establish IV access
• C. Auscultate heart sounds
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps vasodilate coronary arteries, improving blood flow to the heart, relieving chest pain, and preventing cardiac tissue damage. Establishing IV access (choice B) is important but not the preferred initial treatment for unstable angina with chest pain. Auscultating heart sounds (choice C) and obtaining cardiac enzymes (choice D) are relevant assessments but do not address the immediate symptomatic relief needed for a patient with unstable angina and chest pain.

5. A patient reports abdominal cramping after enema administration. What is the appropriate action?

• A. Lower the height of the solution container
• B. Stop the procedure and remove tubing
• C. Increase the flow of enema solution
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

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