Nursing Elites

1. What intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Replace the chest tube system
• C. Clamp 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, the appropriate intervention is to tighten the connections of the chest tube system. This step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.

2. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Administer aspirin
• C. Obtain IV access
• D. Check cardiac enzymes

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps to dilate the blood vessels, reduce the workload on the heart, and improve blood flow to the heart muscle, providing immediate relief for chest pain in acute coronary syndrome. Administering aspirin is also crucial in the early management of acute coronary syndrome to prevent further clot formation. However, in terms of immediate symptom relief, nitroglycerin takes precedence over aspirin. Obtaining IV access is important for administering medications and fluids but is not the priority over providing immediate relief for chest pain. Checking cardiac enzymes is essential for diagnosing acute coronary syndrome but is not the immediate priority when a patient is experiencing chest pain.

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

• A. An air leak
• B. A blocked chest tube
• C. Normal chest tube function
• D. Continuous drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak in the system. This occurs when air is entering the system through a leak, preventing the lung from fully re-expanding. Choice B, a blocked chest tube, is incorrect as a blocked tube would result in a lack of drainage rather than continuous bubbling. Choice C, normal chest tube function, is incorrect as continuous bubbling signifies an issue. Choice D, continuous drainage from the chest tube, is incorrect as bubbling in the water seal chamber specifically indicates an air leak, not just the presence of drainage.

4. What are the expected signs in a patient with compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Fever and infection
• C. Localized redness and swelling
• D. Loss of sensation in the affected area

Correct answer: A

Rationale: In a patient with compartment syndrome, the classic signs include unrelieved pain, pallor, and pulselessness. These signs indicate compromised circulation and neurovascular function in the affected compartment. Fever and infection (Choice B) are not typical signs of compartment syndrome. Localized redness and swelling (Choice C) can be seen in other conditions like cellulitis but are not specific to compartment syndrome. Loss of sensation in the affected area (Choice D) may occur in some cases but is not as specific or consistent as unrelieved pain, pallor, and pulselessness in diagnosing compartment syndrome.

5. A patient with pre-dialysis end-stage kidney disease is asking for dietary recommendations. What should the nurse suggest?

• A. Limit protein intake
• B. Limit potassium intake
• C. Restrict sodium intake
• D. Limit phosphorus intake to 700mg/day

Correct answer: D

Rationale: In patients with pre-dialysis end-stage kidney disease, it is crucial to limit phosphorus intake to 700mg/day to manage their condition. High phosphorus levels can lead to complications such as bone and heart problems. Limiting protein intake is essential in later stages of kidney disease, particularly in dialysis patients to reduce the buildup of waste products. While limiting potassium and restricting sodium intake are also important in kidney disease management, the priority for a patient with pre-dialysis end-stage kidney disease is to control phosphorus levels.

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