Nursing Elites

1. What intervention is needed for continuous bubbling 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: The correct intervention for continuous bubbling in the chest tube water seal chamber is to tighten the connections of the chest tube system. Continuous bubbling indicates an air leak in the system, and tightening the connections can help resolve this issue. Clamping the chest tube (Choice B) is not appropriate and can lead to complications by obstructing the drainage system. Similarly, replacing the entire chest tube system (Choice C) may not be necessary if the issue can be resolved by tightening the connections. Continuing to monitor the chest tube (Choice D) without taking action to address the continuous bubbling may delay necessary interventions to prevent complications.

2. What are the expected symptoms in a patient with compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Localized swelling and redness
• C. Fever and swelling
• D. Weakness and fatigue

Correct answer: A

Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These symptoms are classic signs of compartment syndrome, which is a serious condition characterized by reduced circulation in a closed muscle compartment. The pain is typically severe and disproportionate to the injury, and if left untreated, it can lead to tissue damage and loss of function. Choices B, C, and D are incorrect because they do not represent the hallmark symptoms of compartment syndrome. Localized swelling and redness may be present but are not specific to this condition. Fever and swelling are more indicative of inflammation or infection, while weakness and fatigue are nonspecific and do not typically occur in isolation in compartment syndrome.

3. A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?

• A. Teach the client to report findings of IV extravasation
• B. Evaluate the patency of the IV
• C. Consult with the pharmacist about the prescription
• D. Verify the prescription with the provider

Correct answer: D

Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.

4. What is the priority intervention for a patient with possible acute coronary syndrome?

• A. Administer nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with possible acute coronary syndrome as it helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart. This intervention is crucial in managing acute coronary syndrome and should be given promptly. Getting IV access may be necessary, but administering nitroglycerin takes precedence to alleviate symptoms and prevent further heart damage. Auscultating heart sounds and administering aspirin are important aspects of the assessment and treatment plan, but they are not the priority interventions in the acute phase of suspected acute coronary syndrome.

5. What action should a healthcare provider take if a patient reports 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 reports cramping during enema administration, the best action is to lower the height of the enema solution container. This adjustment helps relieve abdominal cramping by slowing down the flow of the enema, making it more comfortable for the patient. Increasing the flow of the solution (choice B) would exacerbate the cramping. Stopping the procedure and removing the tubing (choice C) may be necessary in some cases but should not be the first response to cramping. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the solution container in addressing the cramping.

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