Nursing Elites

1. What does continuous bubbling in the water seal chamber of a chest tube indicate?

• A. An air leak
• B. Drainage in the chest tube
• C. A blocked chest tube
• D. Normal chest tube function

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This signifies that air is escaping from the patient's pleural space into the chest tube system rather than being evacuated properly. An air leak can lead to lung collapse or pneumothorax and requires immediate attention. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because continuous bubbling does not indicate normal chest tube function, drainage in the chest tube, or a blocked chest tube.

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. 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 to reduce stress
• D. Drink milk as a snack

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in potassium. Potassium-rich foods can exacerbate gastritis symptoms by irritating the stomach lining. Sodium (choice B) is not directly related to gastritis symptoms. Increasing exercise (choice C) can be beneficial for overall health but may not directly impact gastritis. Drinking milk (choice D) can provide temporary relief for some individuals with gastritis due to its coating effect, but it is not a universal recommendation as it can worsen symptoms in some cases.

4. What are the signs of compartment syndrome?

• A. Unrelieved pain, pallor, pulselessness
• B. Muscle weakness, hyporeflexia
• C. Pins-and-needles sensation, swelling
• D. Severe swelling and tightness in the affected extremity

Correct answer: A

Rationale: The correct signs of compartment syndrome include unrelieved pain, pallor, and pulselessness due to increased pressure within a muscle compartment. Choice B, muscle weakness, and hyporeflexia are not typical signs of compartment syndrome. Choice C, pins-and-needles sensation and swelling, are not specific signs of compartment syndrome. Choice D, severe swelling and tightness in the affected extremity, could be seen in compartment syndrome but are not the primary signs.

5. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

• A. After stroking the lateral area of the foot, the client's toes contract and draw together
• B. After hip flexion, the client is unable to extend their leg completely without pain
• C. The client's voluntary movement is not coordinated
• D. The client reports pain and stiffness when flexing their neck

Correct answer: B

Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.

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