Nursing Elites

1. What is the priority nursing action when a patient with chest pain presents with possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Obtain IV access
• C. Check the patient's cardiac enzymes
• D. Administer aspirin

Correct answer: A

Rationale: The priority nursing action when a patient with chest pain presents with possible acute coronary syndrome is to administer sublingual nitroglycerin. Sublingual nitroglycerin helps dilate blood vessels, reducing cardiac workload, and improving blood supply to the heart muscle, thus relieving pain and enhancing blood flow to the heart. While obtaining IV access is important for administering medications and fluids, it is not the priority over addressing pain and improving blood flow. Checking the patient's cardiac enzymes is crucial for diagnosis and ongoing management but not the immediate priority when the patient is in pain. Administering aspirin is also a vital intervention in acute coronary syndrome, but in this scenario, it is not the priority action compared to providing immediate pain relief and enhancing blood flow to the heart.

2. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

• A. Distended, board-like abdomen
• B. WBC count of 15,000/mm3
• C. Rebound tenderness over McBurney's point
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen should be reported to the provider immediately because it indicates peritonitis, a serious complication of appendicitis resulting from a ruptured appendix. Option B, an elevated WBC count, may indicate infection but is not as urgent as a board-like abdomen. Option C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate immediate life-threatening complications. Option D, a slightly elevated temperature, is not as concerning as a distended, board-like abdomen.

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 intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?

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

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate intervention is to tighten the connections of the chest tube system. This step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.

5. What precaution should be advised to a patient following a cataract surgery?

• A. Wear dark glasses while outdoors
• B. Avoid NSAIDs
• C. Use warm compresses
• D. Apply cold packs

Correct answer: A

Rationale: Following cataract surgery, patients are advised to wear dark glasses while outdoors. This is crucial to protect the eyes from bright light and prevent complications such as excessive glare or discomfort. Choice B, avoiding NSAIDs, is not directly related to post-cataract surgery care. Choices C and D, using warm compresses and applying cold packs, are not typically part of the standard post-operative care for cataract surgery.

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