Nursing Elites

1. What is the priority intervention for a patient presenting with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.

2. A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?

• A. There is no fluctuation in the water seal chamber.
• B. There is continuous bubbling in the suction control chamber.
• C. There is tidaling in the water seal chamber.
• D. The drainage system is positioned at the level of the client's chest.

Correct answer: A

Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.

3. What is the priority nursing intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, ensuring adequate oxygenation is the priority. Administering oxygen helps improve oxygen levels, which is crucial for the patient's well-being. Repositioning the patient, administering bronchodilators, or giving IV fluids are important interventions in certain situations, but when a patient is in respiratory distress, providing oxygen takes precedence over other actions.

4. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

• A. Peanut butter and jelly sandwich
• B. Grilled chicken and rice
• C. Tomato soup with saltine crackers
• D. Baked fish and steamed vegetables

Correct answer: D

Rationale: The correct answer is D, baked fish and steamed vegetables. These food choices are low in potassium and phosphorus, which is important for clients with chronic kidney disease to manage their condition effectively. Grilled chicken and rice (choice B) may be high in phosphorus, tomato soup with saltine crackers (choice C) is high in sodium, and a peanut butter and jelly sandwich (choice A) contains high levels of potassium, all of which are not ideal choices for individuals with chronic kidney disease.

5. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

• A. Serum glucose level.
• B. Serum calcium level.
• C. Lymphocyte count.
• D. Serum potassium level.

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, elevated cortisol levels lead to increased gluconeogenesis, insulin resistance, and breakdown of proteins and fats, resulting in elevated blood glucose levels. This is known as hyperglycemia. The other options, including serum calcium level (choice B), lymphocyte count (choice C), and serum potassium level (choice D), are not typically affected by Cushing's disease. Therefore, they are incorrect choices.

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