Nursing Elites

1. What ECG changes are associated with hyperkalemia?

• A. Flattened T waves
• B. ST depression
• C. Prominent U waves
• D. Elevated ST segments

Correct answer: B

Rationale: Hyperkalemia is known to cause ST depression on an ECG. Flattened T waves are more commonly seen in hypokalemia. Prominent U waves are associated with hypokalemia rather than hyperkalemia. Elevated ST segments are not typical findings in hyperkalemia.

2. What should the nurse do for a patient experiencing abdominal cramping during enema administration?

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

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the solution. Choice B, stopping the procedure and removing the tubing, is incorrect as it is too drastic and may not address the cramping. Choice C, continuing the enema at a slower rate, may exacerbate the cramping if the flow rate is still too high. Choice D, increasing the flow of the enema solution, would worsen the cramping and is not the appropriate intervention.

3. What intervention is needed when continuous bubbling is seen in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Clamp the chest tube
• C. Replace 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 action can help resolve an air leak, which is often the cause of continuous bubbling in the water seal chamber. Clamping the chest tube (choice B) is not recommended as it can lead to a dangerous increase in pressure within the chest. Replacing the chest tube (choice C) is not the initial intervention unless there are other indications to do so. Simply monitoring the chest tube (choice D) without taking corrective action will not address the underlying issue of the air leak causing continuous bubbling.

4. What is the first nursing action for a patient with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Increase fluids to prevent dehydration
• C. Obtain cardiac enzymes
• D. Get IV access and auscultate heart sounds

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority nursing action for a patient with chest pain and possible acute coronary syndrome. Nitroglycerin helps dilate the blood vessels, improve blood flow to the heart, and reduce cardiac workload. This action aims to relieve chest pain promptly and prevent further cardiac tissue damage. Increasing fluids is not the initial priority for a patient with chest pain and possible acute coronary syndrome. Obtaining cardiac enzymes is important for diagnosis but is not the first action in managing acute symptoms. Getting IV access and auscultating heart sounds are important interventions, but they come after administering sublingual nitroglycerin in the management of acute coronary syndrome.

5. What are the expected symptoms in a patient with a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Severe headache and confusion
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: A thrombotic stroke typically presents with a gradual loss of function on one side of the body. This gradual onset distinguishes it from a hemorrhagic stroke, which often manifests with sudden and severe symptoms like loss of consciousness (choice B), severe headache and confusion (choice C), or loss of sensation in the affected limb (choice D). Therefore, choices B, C, and D are not typically associated with thrombotic strokes.

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