Nursing Elites

1. A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?

• A. An air leak
• B. A blocked chest tube
• C. Drainage from the site
• D. Blood clot in the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This situation requires immediate attention to prevent complications such as lung collapse. A blocked chest tube would typically result in absent or fluctuating bubbling. Drainage from the site would be observed in the collection chamber, not the water seal chamber. A blood clot in the chest tube would lead to cessation of drainage.

2. A nurse administers insulin for a misread glucose level. What should the nurse monitor for?

• A. Monitor for hypoglycemia
• B. Monitor for hyperglycemia
• C. Monitor for hyperkalemia
• D. Document the incident

Correct answer: A

Rationale: When a nurse administers insulin for a misread glucose level, they should monitor for hypoglycemia. Insulin lowers blood sugar levels, so the patient may experience hypoglycemia if given insulin unnecessarily. Monitoring for hypoglycemia involves observing for symptoms such as shakiness, sweating, dizziness, confusion, and palpitations. Choices B and C are incorrect because administering insulin for a misread glucose level would lower blood sugar levels, resulting in hypoglycemia, not hyperglycemia or hyperkalemia. Choice D is not the immediate priority; the focus should be on patient safety and monitoring for potential adverse effects of the unnecessary insulin.

3. What is the first action a healthcare provider should take for a patient with possible acute coronary syndrome?

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

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the initial priority action for a patient with possible acute coronary syndrome. Nitroglycerin helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart muscle. This helps in relieving symptoms and preventing further damage to the heart. Establishing IV access, auscultating heart sounds, and obtaining cardiac enzymes are important steps in the assessment and management of acute coronary syndrome but are not the first actions to be taken. IV access may be needed for administering medications or fluids, auscultating heart sounds helps in assessing the heart's function, and obtaining cardiac enzymes aids in diagnosing a heart attack.

4. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?

• A. Immunosuppressant medications need to be taken for up to 1 year
• B. Shortness of breath might be an indication of transplant rejection
• C. The surgical site will heal in 3 to 4 weeks after surgery
• D. Begin 45 minutes of moderate aerobic exercise per day following discharge

Correct answer: B

Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.

5. What is the primary concern for a patient with a CD4 T-cell count below 180 cells/mm³?

• A. Increased risk of severe infection
• B. Increased risk of anemia
• C. Increased risk of bleeding
• D. Increased risk of dehydration

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm³ indicates a severely immunocompromised state, leading to an increased risk of severe infection. In individuals with low CD4 counts, the immune system is significantly weakened, making them more susceptible to opportunistic infections. Anemia (choice B), bleeding (choice C), and dehydration (choice D) are not the primary concerns associated with a low CD4 T-cell count. While these conditions may occur as secondary effects or complications, the primary focus is on preventing and managing severe infections in patients with severely compromised immune systems.

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