Nursing Elites

1. A patient reports abdominal cramping during an enema administration. What action should the nurse take?

• A. Increase the flow of the enema
• B. Lower the height of the enema solution container
• C. Stop the enema procedure
• D. Remove the enema tubing

Correct answer: B

Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.

2. What are the early signs of compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Localized redness and swelling
• C. Fever and infection
• D. Loss of sensation in the affected area

Correct answer: A

Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These signs are typical early indicators of compartment syndrome, suggesting compromised circulation. Choice B, localized redness and swelling, can be seen in conditions like cellulitis but are not specific to compartment syndrome. Choice C, fever and infection, are not characteristic early signs of compartment syndrome. Choice D, loss of sensation in the affected area, is more indicative of nerve damage rather than being one of the early signs of compartment syndrome.

3. A nurse is caring for a client with rheumatoid arthritis who has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Weight loss
• B. Hypoglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: C

Rationale: The correct answer is C, 'Hypertension.' Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium retention and potassium loss, leading to increased blood pressure. Weight loss (choice A) is not a common adverse effect of prednisone; in fact, weight gain is more common. Hypoglycemia (choice B) is not typically associated with prednisone use; instead, hyperglycemia is a common concern. Hyperkalemia (choice D) is also unlikely with prednisone use; instead, hypokalemia is a potential electrolyte imbalance.

4. How does hyponatremia place the patient at risk?

• A. Seizures
• B. Fatigue
• C. Cardiac dysrhythmias
• D. Muscle weakness

Correct answer: C

Rationale: Hyponatremia places the patient at risk for cardiac dysrhythmias. While hyponatremia can lead to seizures due to cerebral edema caused by fluid imbalance, the most immediate and life-threatening risk is cardiac dysrhythmias. Low sodium levels can disrupt the heart's electrical activity, potentially leading to fatal arrhythmias. Although fatigue and muscle weakness are symptoms of hyponatremia, cardiac dysrhythmias pose the most critical concern as they can have severe consequences.

5. What intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?

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

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate intervention is to tighten the connections of the chest tube system. This step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.

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