Nursing Elites

1. What intervention is required when continuous bubbling is seen 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
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, tightening the connections of the chest tube system is the appropriate intervention. This action can often resolve an air leak, which is the common cause of continuous bubbling. Clamping the chest tube or replacing it is not recommended as the first-line intervention because it may lead to complications or unnecessary tube changes. Continuing to monitor the chest tube without addressing the air leak would delay necessary corrective action, potentially causing respiratory compromise in the patient. Therefore, tightening the connections of the chest tube system is the most suitable initial step to manage continuous bubbling in the water seal chamber.

2. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

• A. I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league.
• B. I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running.
• C. I'm so upset that this happened to me. What did I do to deserve this?
• D. I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family.

Correct answer: A

Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.

3. 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.

4. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?

• A. Breath sounds
• B. Temperature
• C. Blood pressure
• D. Creatine kinase

Correct answer: A

Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.

5. What are the expected findings in a patient with a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Severe headache and vomiting
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. In a thrombotic stroke, a blood clot forms in an artery supplying blood to the brain, leading to reduced blood flow to a specific area of the brain. This results in a gradual onset of neurological deficits, such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache and vomiting, and loss of sensation in the affected limb are more commonly associated with other types of strokes or medical conditions, not specifically thrombotic strokes. Thrombotic strokes typically present with gradual symptoms due to the gradual blockage of blood flow, leading to a progressive neurological deficit.

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