Nursing Elites

1. 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.

2. The nurse misread a patient's glucose as 210 mg/dL instead of 120 mg/dL and administered the insulin dose for a reading over 200 mg/dL. What is the priority action?

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

Correct answer: C

Rationale: The priority action is to monitor the patient for signs of hypoglycemia as the nurse administered excess insulin due to misreading the glucose level. Administering glucose IV (Choice A) is not the immediate priority when dealing with hypoglycemia. Monitoring for hyperglycemia (Choice B) is not the correct action as the insulin was administered for a higher glucose reading. Documenting the incident (Choice D) is important but not the priority when the patient's safety is at risk due to possible hypoglycemia.

3. A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?

• A. This medication can cause your urine to turn a dark color.
• B. Expect immediate relief after taking this medication.
• C. Take the medication with a high protein food.
• D. Skip a dose of the medication if you experience dizziness.

Correct answer: A

Rationale: The correct instruction to include in the teaching is that carbidopa/levodopa can cause the client's urine to turn a dark color, which is a harmless effect. It is crucial for the nurse to educate the client about this common side effect. Choice B is incorrect because immediate relief is not expected; therapeutic effects may take weeks to months. Choice C is incorrect as carbidopa/levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect as the client should not skip doses without consulting their healthcare provider, even if they experience dizziness.

4. A client is being taught about fecal occult blood testing (FOBT) for colorectal cancer screening. Which of the following statements should the nurse include in the teaching?

• A. Your provider will use a stool sample obtained during a digital rectal examination to perform the test.
• B. Your provider will recommend a stimulant laxative before the test to empty the bowel.
• C. You should start annual fecal occult blood testing for colorectal cancer screening at the age of 40.
• D. You should avoid corticosteroids before the test.

Correct answer: D

Rationale: The correct answer is D because the nurse should advise the client to avoid corticosteroids, anti-inflammatory medications, and vitamin C before fecal occult blood testing to prevent false-positive results. Choice A is incorrect as stool samples for FOBT are usually collected using a kit at home. Choice B is incorrect because stimulant laxatives are not typically used before FOBT. Choice C is incorrect as guidelines recommend starting colorectal cancer screening at the age of 50, not 40.

5. What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?

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

Correct answer: A

Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.

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