Nursing Elites

1. What is the first action when continuous bubbling is observed 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: When continuous bubbling is observed in the chest tube water seal chamber, the first action should be to tighten the connections of the chest tube system. This step is crucial as it can often resolve an air leak causing continuous bubbling. Clamping the chest tube or replacing the chest tube system would not address the underlying issue of loose connections and may not be necessary. Continuing to monitor the chest tube without taking corrective action may lead to complications if the air leak is not addressed promptly.

2. A patient reports abdominal cramping after enema administration. What is the appropriate action?

• A. Lower the height of the solution container
• B. Stop the procedure and remove tubing
• C. Increase the flow of enema solution
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

3. What lab value should be prioritized in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Hemoglobin levels
• C. Serum albumin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. In a patient with HIV, monitoring the CD4 T-cell count is crucial as it reflects the status of the immune system. A CD4 T-cell count below 200 cells/mm3 indicates severe immunocompromise and risk of opportunistic infections. Hemoglobin levels (choice B) are important for assessing anemia but do not directly reflect the immune status in HIV patients. Serum albumin levels (choice C) are indicators of nutritional status and inflammation, not specific to HIV disease progression. White blood cell count (choice D) may fluctuate due to various conditions and is not as specific as the CD4 T-cell count in assessing HIV progression.

4. What dietary teaching should be provided to a patient with pre-dialysis end-stage kidney disease?

• A. Limit phosphorus intake to 700 mg/day
• B. Increase protein intake to 1.5 g/kg/day
• C. Restrict sodium intake to 1 g/day
• D. Increase potassium intake to 3 g/day

Correct answer: A

Rationale: The correct answer is to limit phosphorus intake to 700 mg/day for a patient with pre-dialysis end-stage kidney disease. Excess phosphorus can lead to complications such as bone and heart issues in these patients. Increasing protein intake (Choice B) is generally not recommended as it can lead to increased waste production that the kidneys may struggle to eliminate. Restricting sodium intake (Choice C) is important for managing blood pressure, but the recommendation is usually higher than 1 g/day. Increasing potassium intake (Choice D) is not typically advised in patients with kidney disease, as they often need to limit potassium due to impaired kidney function.

5. What is the primary concern for a patient with a CD4 T-cell count below 180 cells/mm³?

• A. Increased risk of severe infection
• B. Increased risk of anemia
• C. Increased risk of bleeding
• D. Increased risk of dehydration

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm³ indicates a severely immunocompromised state, leading to an increased risk of severe infection. In individuals with low CD4 counts, the immune system is significantly weakened, making them more susceptible to opportunistic infections. Anemia (choice B), bleeding (choice C), and dehydration (choice D) are not the primary concerns associated with a low CD4 T-cell count. While these conditions may occur as secondary effects or complications, the primary focus is on preventing and managing severe infections in patients with severely compromised immune systems.

Similar Questions