Nursing Elites

1. What are the manifestations of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe nausea and vomiting
• C. Elevated blood pressure and bradycardia
• D. Decreased heart rate and altered pupil response

Correct answer: A

Rationale: The correct manifestations of increased intracranial pressure (IICP) include restlessness, confusion, and irritability. These symptoms are a result of the brain being under pressure inside the skull. Severe nausea and vomiting (Choice B) are more commonly associated with increased intracranial pressure in children. Elevated blood pressure and bradycardia (Choice C) are not typical manifestations of increased intracranial pressure; instead, hypertension and bradycardia may be seen in Cushing's reflex, which is a late sign of increased IICP. Decreased heart rate and altered pupil response (Choice D) are also not primary manifestations of increased intracranial pressure, although altered pupil response, like a non-reactive or dilated pupil, can be seen in some cases.

2. During an escharotomy on a patient with a burn injury, what is the purpose of this procedure?

• A. To release pressure and improve circulation in the affected area
• B. To remove dead tissue from the burn area
• C. To improve breathing by reducing skin tightness
• D. To prevent infection in the burned area

Correct answer: A

Rationale: Corrected Question: During an escharotomy on a patient with a burn injury, the purpose of this procedure is to release pressure and improve circulation in the affected area. This intervention is crucial in severe burns where the formation of eschar (dead tissue) can lead to increased pressure, compromising circulation and potentially causing further tissue damage. Choices B, C, and D are incorrect because escharotomy specifically aims to address pressure and circulation issues in severe burn injuries, rather than removing dead tissue, improving breathing, or preventing infection.

3. What should the nurse do if a patient experiences abdominal cramping during enema administration?

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

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the solution container. This adjustment can help alleviate the cramping by reducing the speed and pressure of the solution entering the colon. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in extreme cases but is not the initial step. Continuing the enema at a slower rate (Choice D) may not effectively address the cramping, making it less optimal than lowering the height of the solution container.

4. What is the priority intervention when continuous bubbling is observed in the water seal chamber of a chest tube?

• A. Check for an air leak
• B. Continue monitoring as it is not normal
• C. Replace the chest tube system
• D. Tighten the tube connections

Correct answer: A

Rationale: The correct answer is to 'Check for an air leak.' Continuous bubbling in the water seal chamber of a chest tube indicates an air leak, which can compromise the effectiveness of the chest tube in re-expanding the lung. Checking for an air leak is crucial to prevent respiratory complications. Choice B is incorrect because continuous bubbling is not normal and requires immediate intervention to address the air leak. Choice C is incorrect as replacing the entire chest tube system is not the initial priority when an air leak is suspected. Choice D is incorrect because tightening tube connections may not address the underlying issue of an air leak and should not be the initial action taken in this situation.

5. What is the first medication to give for wheezing due to an allergic reaction?

• A. Albuterol via nebulizer
• B. Cromolyn 20 mg via nebulizer
• C. Methylprednisolone 100 mg IV
• D. Aminophylline 500 mg IV

Correct answer: A

Rationale: Albuterol is the first-line medication for treating wheezing due to an allergic reaction. Albuterol is a short-acting beta-agonist that helps relieve bronchospasm quickly. Cromolyn is more commonly used for the prevention of asthma symptoms rather than for acute treatment. Methylprednisolone and aminophylline are not the first-line medications for acute wheezing due to an allergic reaction.

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