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. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?

• A. It delivers a preset amount of inspiratory pressure throughout the breathing cycle
• B. It has a continuous adjustment feature that changes the airway pressure throughout the cycle
• C. It delivers a preset amount of airway pressure throughout the breathing cycle
• D. It delivers positive pressure at the end of each breath

Correct answer: C

Rationale: The correct answer is C because a CPAP device delivers a preset amount of positive airway pressure continuously throughout all inspiration and expiration cycles. Choice A is incorrect because CPAP does not deliver inspiratory pressure at the beginning of each breath; it provides continuous positive pressure. Choice B is incorrect because CPAP typically delivers a constant pressure rather than having a feature that changes pressure throughout the cycle. Choice D is incorrect as CPAP does not deliver positive pressure specifically at the end of each breath; it maintains a consistent pressure throughout the breathing cycle.

3. What intervention is needed for continuous bubbling 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: The correct intervention for continuous bubbling in the chest tube water seal chamber is to tighten the connections of the chest tube system. Continuous bubbling indicates an air leak in the system, and tightening the connections can help resolve this issue. Clamping the chest tube (Choice B) is not appropriate and can lead to complications by obstructing the drainage system. Similarly, replacing the entire chest tube system (Choice C) may not be necessary if the issue can be resolved by tightening the connections. Continuing to monitor the chest tube (Choice D) without taking action to address the continuous bubbling may delay necessary interventions to prevent complications.

4. What is the first action a healthcare provider should take for a patient with possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the initial priority action for a patient with possible acute coronary syndrome. Nitroglycerin helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart muscle. This helps in relieving symptoms and preventing further damage to the heart. Establishing IV access, auscultating heart sounds, and obtaining cardiac enzymes are important steps in the assessment and management of acute coronary syndrome but are not the first actions to be taken. IV access may be needed for administering medications or fluids, auscultating heart sounds helps in assessing the heart's function, and obtaining cardiac enzymes aids in diagnosing a heart attack.

5. What should a healthcare provider monitor for in a patient with hypokalemia?

• A. Monitor for muscle weakness
• B. Monitor for bradycardia
• C. Check deep tendon reflexes
• D. Monitor for hyperglycemia

Correct answer: A

Rationale: Corrected Rationale: Muscle weakness is a common symptom of hypokalemia and should be closely monitored in affected patients. Hypokalemia is a condition characterized by low potassium levels in the blood, which can lead to muscle weakness, cramps, and even paralysis. While bradycardia (slow heart rate) can be associated with severe hypokalemia, monitoring for muscle weakness is more specific to the condition. Checking deep tendon reflexes is not typically a primary monitoring parameter for hypokalemia. Monitoring for hyperglycemia is not directly related to hypokalemia, as hypokalemia is primarily associated with potassium levels in the blood.

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