Nursing Elites

1. What is the first nursing action for a patient admitted with chest pain from acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Check the patient's urine output
• C. Administer IV fluids
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action for a patient admitted with chest pain from acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Checking the patient's urine output (Choice B) is not the priority in this situation. Administering IV fluids (Choice C) may not be necessary unless indicated by the patient's condition. Obtaining cardiac enzymes (Choice D) is important but is not the initial action needed to address the patient's acute symptoms.

2. What is a characteristic sign of hypokalemia on an ECG?

• A. Flattened T waves
• B. ST elevation
• C. Prominent U waves
• D. Widened QRS complex

Correct answer: A

Rationale: Flattened T waves are a characteristic sign of hypokalemia on an ECG. When potassium levels are low, it can lead to changes in the ECG, such as T wave flattening. This alteration is important to recognize as it indicates potential electrolyte imbalances. ST elevation (Choice B) is not typically associated with hypokalemia but can be seen in conditions like myocardial infarction. Prominent U waves (Choice C) are associated with hypokalemia, but flattened T waves are more specific. Widened QRS complex (Choice D) is not a typical ECG finding in hypokalemia but can be seen in conditions like hyperkalemia.

3. What is the priority action when the nurse administers insulin for a misread blood glucose reading?

• A. Monitor for signs of hypoglycemia
• B. Monitor for hyperglycemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.

4. When caring for a patient with hypokalemia, what should the nurse monitor for?

• A. Monitor for muscle weakness
• B. Check for cardiac dysrhythmias
• C. Monitor for bradycardia
• D. Monitor for seizures

Correct answer: A

Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.

5. What intervention is needed for a patient with a chest tube and an air leak?

• A. Tighten the connections of the chest tube system
• B. Replace the chest tube
• C. Clamp the chest tube
• D. Continue to monitor the chest tube

Correct answer: A

Rationale: The correct intervention for a patient with a chest tube and an air leak is to tighten the connections of the chest tube system. This step helps prevent air leaks and ensures the proper functioning of the chest tube. Choice B, replacing the chest tube, is not necessary as tightening the connections should be attempted first. Clamping the chest tube (Choice C) is not recommended as it can lead to complications by obstructing the drainage system. Continuing to monitor the chest tube (Choice D) without taking action may result in worsening of the air leak. Therefore, the priority intervention is to tighten the connections of the chest tube system.

Similar Questions