What should be the priority action when a patient is admitted with chest pain from acute coronary syndrome?

A. Administer sublingual nitroglycerin

B. Obtain IV access

C. Check cardiac enzymes

D. Administer aspirin

Correct Answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action in treating chest pain associated with acute coronary syndrome as it helps to dilate blood vessels, improve blood flow to the heart, and reduce cardiac tissue damage. Administering nitroglycerin is crucial in managing the symptoms and potential complications of acute coronary syndrome. Obtaining IV access (Choice B) is important for administering medications and fluids but does not address the immediate symptom of chest pain. Checking cardiac enzymes (Choice C) and administering aspirin (Choice D) are essential steps in the management of acute coronary syndrome, but they should follow the administration of nitroglycerin to address the immediate symptom and improve blood flow to the heart.

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.

A client with heart failure is prescribed furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include during discharge teaching?

• A. Monitor for increased blood pressure
• B. Increase intake of high-potassium foods
• C. Expect an increase in swelling in the hands and feet
• D. Take the second dose at bedtime

Correct Answer: B
Rationale: The correct answer is to instruct the client to increase their intake of high-potassium foods. Furosemide can lead to hypokalemia, a condition of low potassium levels in the blood. Increasing the consumption of high-potassium foods helps prevent this adverse effect. Monitoring for increased blood pressure (choice A) is not directly related to furosemide use. Expecting an increase in swelling (choice C) is incorrect as furosemide is a diuretic that helps reduce swelling. Taking the second dose at bedtime (choice D) is not necessary unless prescribed by the healthcare provider.

What is the priority action when a healthcare professional misreads a glucose reading and administers excess insulin?

• A. Administer IV glucose
• B. Monitor for hyperglycemia
• C. Monitor for hypoglycemia
• D. Document the incident

Correct Answer: C
Rationale: The priority action when a healthcare professional misreads a glucose reading and administers excess insulin is to monitor for hypoglycemia. Excess insulin can lead to dangerously low blood sugar levels (hypoglycemia), which can result in serious complications. Monitoring for hypoglycemia allows for timely identification and intervention to prevent harm. Administering IV glucose may be necessary if hypoglycemia occurs. Monitoring for hyperglycemia is not the priority in this situation, as excess insulin would lower blood sugar levels. Documenting the incident is important for reporting and quality improvement purposes but should not take precedence over ensuring patient safety by monitoring for hypoglycemia.

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.