Nursing Elites

1. A patient is admitted with chest pain, possible acute coronary syndrome. What should the nurse do first?

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

Correct answer: A

Rationale: In a patient with chest pain, possible acute coronary syndrome, the nurse should administer sublingual nitroglycerin first. Nitroglycerin helps to vasodilate coronary arteries, improving blood flow to the heart, and reducing cardiac workload. This can alleviate chest pain and decrease cardiac tissue damage in acute coronary syndrome. Getting IV access, obtaining cardiac enzymes, and auscultating heart sounds are important steps in the assessment and management of acute coronary syndrome, but administering nitroglycerin to relieve chest pain and improve blood flow takes precedence as it directly addresses the patient's symptoms and aims to prevent further cardiac damage.

2. What are the common manifestations of compartment syndrome?

• A. Unrelieved pain, pallor, pulselessness
• B. Redness and swelling
• C. Fever and infection
• D. Swelling and redness

Correct answer: A

Rationale: The correct manifestations of compartment syndrome are unrelieved pain, pallor, and pulselessness. These symptoms indicate compromised blood flow and neurovascular compromise, necessitating immediate medical intervention. Redness and swelling (Choice B) are more commonly associated with inflammation or infection rather than compartment syndrome. Fever and infection (Choice C) are not typical manifestations of compartment syndrome. Swelling and redness (Choice D) are general signs that can be seen in various conditions and are not specific to compartment syndrome.

3. What is the priority intervention for a patient with unstable angina?

• A. Administer nitroglycerin
• B. Establish IV access
• C. Auscultate heart sounds
• D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.

4. A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?

• A. Flail chest
• B. Hemothorax
• C. Pulmonary contusion
• D. Pneumothorax

Correct answer: A

Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.

5. What are the expected manifestations in a patient experiencing a thrombotic stroke?

• A. Sudden numbness or loss of function on one side of the body
• B. Sudden loss of consciousness and seizure
• C. Gradual onset of difficulty speaking
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct manifestation in a patient experiencing a thrombotic stroke is sudden numbness or loss of function on one side of the body. This is due to the blockage of a blood vessel by a clot, leading to a lack of blood flow to a specific part of the brain. Choices B, C, and D are incorrect. Sudden loss of consciousness and seizure are more commonly associated with hemorrhagic strokes. Gradual onset of difficulty speaking is often seen in ischemic strokes affecting language areas, not specifically in thrombotic strokes. Loss of sensation in the affected limb is more indicative of sensory nerve damage rather than the motor deficits seen in thrombotic strokes.

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