Nursing Elites

1. What intervention is needed for a patient with a chest tube and an air leak?

• A. Tighten the connections of the chest tube system
• B. Replace the chest tube
• C. Clamp the chest tube
• D. Continue to monitor the chest tube

Correct answer: A

Rationale: The correct intervention for a patient with a chest tube and an air leak is to tighten the connections of the chest tube system. This step helps prevent air leaks and ensures the proper functioning of the chest tube. Choice B, replacing the chest tube, is not necessary as tightening the connections should be attempted first. Clamping the chest tube (Choice C) is not recommended as it can lead to complications by obstructing the drainage system. Continuing to monitor the chest tube (Choice D) without taking action may result in worsening of the air leak. Therefore, the priority intervention is to tighten the connections of the chest tube system.

2. 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.

3. A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?

• A. Eat three large meals daily
• B. Consume high-calorie foods
• C. Limit caffeinated drinks to two per day
• D. Drink fluids during meal time

Correct answer: B

Rationale: The correct answer is B: 'Consume high-calorie foods.' Clients with COPD often have increased energy needs due to the work of breathing. Consuming high-calorie, high-protein foods can help provide the necessary energy and prevent weight loss. Choice A is incorrect because eating three large meals daily may lead to increased shortness of breath due to a full stomach putting pressure on the diaphragm. Choice C is incorrect because caffeinated drinks can contribute to dehydration, which is not ideal for clients with COPD. Choice D is incorrect because drinking fluids during mealtime can cause bloating and early satiety, making it difficult for clients to consume enough calories.

4. A nurse is caring for a client with rheumatoid arthritis who has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Weight loss
• B. Hypoglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: C

Rationale: The correct answer is C, 'Hypertension.' Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium retention and potassium loss, leading to increased blood pressure. Weight loss (choice A) is not a common adverse effect of prednisone; in fact, weight gain is more common. Hypoglycemia (choice B) is not typically associated with prednisone use; instead, hyperglycemia is a common concern. Hyperkalemia (choice D) is also unlikely with prednisone use; instead, hypokalemia is a potential electrolyte imbalance.

5. What should the healthcare provider do first when a patient is admitted with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority intervention when a patient presents with chest pain and suspected acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. It is crucial to address the pain and potential ischemia promptly to prevent further cardiac tissue damage. Getting IV access, auscultating heart sounds, and obtaining cardiac enzymes are important assessments and interventions, but administering nitroglycerin takes precedence in managing acute coronary syndrome.

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