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 is a typical symptom of a hemorrhagic stroke in a patient?

• A. Sudden, severe headache
• B. Gradual onset of numbness
• C. Loss of consciousness
• D. Loss of speech ability

Correct answer: A

Rationale: A sudden, severe headache is a common symptom of a hemorrhagic stroke due to brain bleeding. This headache is often described as the worst headache of one's life. Gradual onset of numbness (choice B) is more characteristic of an ischemic stroke, where a blood clot blocks an artery in the brain. Loss of consciousness (choice C) can occur in severe cases of stroke but is not specific to hemorrhagic strokes. Loss of speech ability (choice D) is more associated with ischemic strokes affecting language centers of the brain.

3. 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.

4. A patient who experienced an acute episode of gastritis should avoid which type of foods?

• A. Avoid foods high in potassium
• B. Avoid foods high in sodium
• C. Increase exercise
• D. Drink milk as a snack

Correct answer: A

Rationale: Patients who have experienced an acute episode of gastritis should avoid foods high in potassium. Potassium-rich foods can irritate the gastric lining, exacerbating gastritis symptoms. Therefore, choices B, C, and D are incorrect. Avoiding foods high in sodium is beneficial for other health conditions like hypertension, increasing exercise is generally good for overall health but not specifically for gastritis management, and drinking milk may provide temporary relief for some but is not a definitive recommendation for gastritis management.

5. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?

• A. Apply an ice pack directly to the affected area
• B. Immobilize the affected extremity with a splint
• C. Place a tourniquet above and below the affected area
• D. Elevate the affected extremity

Correct answer: B

Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.

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