Nursing Elites

1. What should the healthcare provider do if a patient presents with chest pain and possible acute coronary syndrome?

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

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority action in the treatment of chest pain in acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain. Aspirin can also be given to reduce clot formation, but nitroglycerin takes precedence in providing immediate relief. Obtaining cardiac enzymes and assessing heart sounds are important steps in the diagnostic process but do not address the immediate need to relieve chest pain and prevent cardiac tissue damage. Therefore, administering sublingual nitroglycerin is the most appropriate initial intervention for a patient presenting with chest pain and possible acute coronary syndrome.

2. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

• A. After stroking the lateral area of the foot, the client's toes contract and draw together
• B. After hip flexion, the client is unable to extend their leg completely without pain
• C. The client's voluntary movement is not coordinated
• D. The client reports pain and stiffness when flexing their neck

Correct answer: B

Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.

3. What is the initial action for treating chest pain in acute coronary syndrome?

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

Correct answer: A

Rationale: The correct initial action for treating chest pain in acute coronary syndrome is to administer sublingual nitroglycerin. Nitroglycerin helps dilate blood vessels, reducing the workload on the heart and improving blood flow to the heart muscle. Administering aspirin can also be beneficial, but the priority is to address chest pain promptly. Checking cardiac enzymes and obtaining IV access are important steps but are not the initial actions needed to alleviate chest pain in acute coronary syndrome.

4. What are the expected symptoms in a patient experiencing a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Seizures and convulsions
• D. Severe headache and vomiting

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' Thrombotic strokes typically result in a gradual onset of symptoms due to a blockage in a blood vessel in the brain, leading to a slow progression of neurological deficits. Choices B, C, and D are incorrect because sudden loss of consciousness, seizures, convulsions, severe headache, and vomiting are more commonly associated with other types of strokes or medical conditions, such as hemorrhagic strokes, epilepsy, or migraines.

5. A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?

• A. An air leak
• B. A blocked chest tube
• C. Drainage from the site
• D. Blood clot in the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This situation requires immediate attention to prevent complications such as lung collapse. A blocked chest tube would typically result in absent or fluctuating bubbling. Drainage from the site would be observed in the collection chamber, not the water seal chamber. A blood clot in the chest tube would lead to cessation of drainage.

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