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. What should be included in teaching for a patient with pre-dialysis end-stage kidney disease?

• A. Limit phosphorus intake to 700 mg/day
• B. Increase protein intake to 1g/kg/day
• C. Increase sodium intake
• D. Limit sodium to 1,500 mg/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. Excessive phosphorus intake can lead to further complications in kidney disease, such as bone and cardiovascular issues. Choice B is incorrect as increasing protein intake can put additional stress on the kidneys due to the buildup of urea and other waste products. Choice C is incorrect because increasing sodium intake can worsen hypertension and fluid retention, common issues in kidney disease. Choice D is incorrect as limiting sodium intake is generally recommended in kidney disease to manage blood pressure and fluid balance.

3. What are the expected signs of compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Fever, swelling, and redness
• C. Muscle cramps and weakness
• D. Redness and itching

Correct answer: A

Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to inadequate blood supply. This results in severe pain that is unrelieved by rest or medication, pallor due to compromised blood flow, and pulselessness as a late sign of severe ischemia. Choices B, C, and D are incorrect. Fever, swelling, and redness are not typical signs of compartment syndrome. Muscle cramps and weakness may occur due to other conditions, but they are not primary indicators of compartment syndrome. Redness and itching are also not commonly associated with compartment syndrome.

4. What should a healthcare professional monitor in a patient receiving insulin who is at risk for hypoglycemia?

• A. Monitor blood glucose levels
• B. Monitor for respiratory distress
• C. Monitor for muscle weakness
• D. Monitor for hyperkalemia

Correct answer: A

Rationale: Monitoring blood glucose levels is crucial in patients receiving insulin who are at risk for hypoglycemia. Insulin can lower blood sugar levels, potentially leading to hypoglycemia, which can be harmful if not promptly recognized and managed. Checking blood glucose levels allows for early detection of low blood sugar levels, enabling timely interventions to prevent complications. Choices B, C, and D are incorrect as they do not directly relate to monitoring for hypoglycemia in patients receiving insulin.

5. What is the priority action if a patient experiences hypoglycemia after an insulin dose?

• A. Check the patient's blood glucose level
• B. Administer IV dextrose
• C. Document the incident
• D. Continue monitoring the patient

Correct answer: A

Rationale: The priority action when a patient experiences hypoglycemia after an insulin dose is to check the patient's blood glucose level. This is crucial to confirm hypoglycemia before initiating any treatment. While administering IV dextrose may be necessary if the patient's blood glucose level is critically low, confirming hypoglycemia is essential to guide appropriate interventions. Documenting the incident is important for documentation purposes but is not the immediate priority when the patient's safety is at risk. Continuing to monitor the patient is essential, but it should follow the confirmation and initial management of hypoglycemia.

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