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. What intervention is needed 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 correct intervention is to tighten the connections of the chest tube system. This can help resolve an air leak that is causing the continuous bubbling. Clamping the chest tube or replacing the entire chest tube system are not appropriate interventions in this scenario. Clamping the tube can lead to a dangerous buildup of pressure, while replacing the chest tube system may not be necessary if the issue can be resolved by simply tightening the connections. Continuing to monitor the chest tube without taking corrective action may lead to complications associated with the air leak.

3. A patient reports abdominal cramping during an enema administration. What action should the nurse take?

• A. Increase the flow of the enema
• B. Lower the height of the enema solution container
• C. Stop the enema procedure
• D. Remove the enema tubing

Correct answer: B

Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.

4. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?

• A. Apply an ice pack directly to the affected area
• B. Immobilize the affected extremity with a splint
• C. Place a tourniquet above and below the affected area
• D. Elevate the affected extremity

Correct answer: B

Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.

5. What are the expected ECG findings in hypokalemia?

• A. Flattened T waves
• B. Prominent U waves
• C. Elevated ST segments
• D. Wide QRS complex

Correct answer: A

Rationale: Flattened T waves are the classic ECG finding in hypokalemia. Hypokalemia primarily affects the repolarization phase of the cardiac action potential, leading to T wave abnormalities. While prominent U waves are typically associated with hypokalemia as well, flattened T waves are the most specific and sensitive ECG abnormality seen in hypokalemia. Elevated ST segments and wide QRS complexes are not typically seen in hypokalemia and are more indicative of other electrolyte imbalances or cardiac conditions.

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