Nursing Elites

1. What should the nurse do when continuous bubbling is seen 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
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the nurse should tighten the connections of the chest tube system. This action can often resolve an air leak causing the continuous bubbling. Clamping the chest tube or replacing it would not address the underlying issue of an air leak and may lead to complications. Continuing to monitor the chest tube without taking corrective action may result in the deterioration of the patient's condition.

2. What action should a healthcare provider take if a patient reports cramping during enema administration?

• A. Lower the height of the solution container
• B. Increase the flow of the enema solution
• C. Stop the procedure and remove the tubing
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: When a patient reports cramping during enema administration, the best action is to lower the height of the enema solution container. This adjustment helps relieve abdominal cramping by slowing down the flow of the enema, making it more comfortable for the patient. Increasing the flow of the solution (choice B) would exacerbate the cramping. Stopping the procedure and removing the tubing (choice C) may be necessary in some cases but should not be the first response to cramping. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the solution container in addressing the cramping.

3. What is the first nursing action for a patient with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Increase fluids to prevent dehydration
• C. Obtain cardiac enzymes
• D. Get IV access and auscultate heart sounds

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority nursing action for a patient with chest pain and possible acute coronary syndrome. Nitroglycerin helps dilate the blood vessels, improve blood flow to the heart, and reduce cardiac workload. This action aims to relieve chest pain promptly and prevent further cardiac tissue damage. Increasing fluids is not the initial priority for a patient with chest pain and possible acute coronary syndrome. Obtaining cardiac enzymes is important for diagnosis but is not the first action in managing acute symptoms. Getting IV access and auscultating heart sounds are important interventions, but they come after administering sublingual nitroglycerin in the management of acute coronary syndrome.

4. What is an escharotomy and why is it performed?

• A. A surgical incision made to improve circulation in burn injuries
• B. A procedure to remove dead tissue from a wound
• C. A procedure to remove excess fluid from the lungs
• D. A procedure to relieve pain from burns

Correct answer: A

Rationale: An escharotomy is a surgical procedure involving an incision through the eschar (dead tissue) to relieve pressure in burn injuries. It is performed to improve circulation to the affected area, prevent further damage, and restore blood flow. Choice B is incorrect because an escharotomy is not primarily focused on removing dead tissue but rather on relieving pressure. Choice C is incorrect as it describes a procedure related to pulmonary issues, not burn injuries. Choice D is incorrect because while pain relief may be a result of an escharotomy, it is not the primary purpose of the procedure.

5. What should the nurse do if a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the solution container
• B. Increase the flow of the enema solution
• C. Stop the procedure and remove the tubing
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the solution container. This adjustment can help alleviate the cramping by reducing the speed and pressure of the solution entering the colon. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in extreme cases but is not the initial step. Continuing the enema at a slower rate (Choice D) may not effectively address the cramping, making it less optimal than lowering the height of the solution container.

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