Nursing Elites

1. What are the signs and symptoms of a hemorrhagic stroke?

• A. Sudden severe headache, decreased level of consciousness, and seizures
• B. Loss of consciousness and weakness
• C. Temporary vision loss
• D. Severe chest pain and shortness of breath

Correct answer: A

Rationale: The correct answer is A. A hemorrhagic stroke often presents with a sudden severe headache, decreased level of consciousness, and seizures due to bleeding in the brain. Choice B, loss of consciousness and weakness, is more indicative of an ischemic stroke where a clot blocks blood flow to the brain. Choice C, temporary vision loss, is more commonly seen in conditions like transient ischemic attacks (TIAs) or retinal migraines. Choice D, severe chest pain and shortness of breath, are symptoms more associated with cardiac issues like a heart attack.

2. What is the first nursing action for a patient admitted with chest pain from acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Check the patient's urine output
• C. Administer IV fluids
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action for a patient admitted with chest pain from acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Checking the patient's urine output (Choice B) is not the priority in this situation. Administering IV fluids (Choice C) may not be necessary unless indicated by the patient's condition. Obtaining cardiac enzymes (Choice D) is important but is not the initial action needed to address the patient's acute symptoms.

3. What intervention is needed when continuous bubbling is observed 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 system
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the correct intervention is to tighten the connections of the chest tube system. This can help resolve an air leak that is causing the continuous bubbling. Clamping the chest tube or replacing the entire chest tube system are not appropriate interventions in this scenario. Clamping the tube can lead to a dangerous buildup of pressure, while replacing the chest tube system may not be necessary if the issue can be resolved by simply tightening the connections. Continuing to monitor the chest tube without taking corrective action may lead to complications associated with the air leak.

4. What dietary teaching should be provided to a patient with pre-dialysis end-stage kidney disease?

• A. Limit phosphorus intake to 700 mg/day
• B. Increase protein intake to 1.5 g/kg/day
• C. Restrict sodium intake to 1 g/day
• D. Increase potassium intake to 3 g/day

Correct answer: A

Rationale: The correct answer is to limit phosphorus intake to 700 mg/day for a patient with pre-dialysis end-stage kidney disease. Excess phosphorus can lead to complications such as bone and heart issues in these patients. Increasing protein intake (Choice B) is generally not recommended as it can lead to increased waste production that the kidneys may struggle to eliminate. Restricting sodium intake (Choice C) is important for managing blood pressure, but the recommendation is usually higher than 1 g/day. Increasing potassium intake (Choice D) is not typically advised in patients with kidney disease, as they often need to limit potassium due to impaired kidney function.

5. 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.

Similar Questions