Nursing Elites

1. A nurse administers insulin for a misread glucose level. What should the nurse monitor for?

• A. Monitor for hypoglycemia
• B. Monitor for hyperglycemia
• C. Monitor for hyperkalemia
• D. Document the incident

Correct answer: A

Rationale: When a nurse administers insulin for a misread glucose level, they should monitor for hypoglycemia. Insulin lowers blood sugar levels, so the patient may experience hypoglycemia if given insulin unnecessarily. Monitoring for hypoglycemia involves observing for symptoms such as shakiness, sweating, dizziness, confusion, and palpitations. Choices B and C are incorrect because administering insulin for a misread glucose level would lower blood sugar levels, resulting in hypoglycemia, not hyperglycemia or hyperkalemia. Choice D is not the immediate priority; the focus should be on patient safety and monitoring for potential adverse effects of the unnecessary insulin.

2. What are the signs and symptoms of Increased Intracranial Pressure (IICP)?

• A. Irritability, confusion, restlessness
• B. Fatigue and SOB
• C. Changes in pupillary response
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Irritability, confusion, restlessness. These are common signs of Increased Intracranial Pressure (IICP) as they result from the increased pressure on brain tissue. Choices B, C, and D are incorrect. Fatigue and shortness of breath (SOB) are not typical symptoms of IICP. Changes in pupillary response can be seen in other conditions but are not specific to IICP. Elevated blood pressure is not a common sign of IICP.

3. What intervention is required 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, tightening the connections of the chest tube system is the appropriate intervention. This action can often resolve an air leak, which is the common cause of continuous bubbling. Clamping the chest tube or replacing it is not recommended as the first-line intervention because it may lead to complications or unnecessary tube changes. Continuing to monitor the chest tube without addressing the air leak would delay necessary corrective action, potentially causing respiratory compromise in the patient. Therefore, tightening the connections of the chest tube system is the most suitable initial step to manage continuous bubbling in the water seal chamber.

4. A patient reports abdominal cramping after enema administration. What is the appropriate action?

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

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

5. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

• A. Axillary temperature 37.2°C (99°F)
• B. Apical pulse 100/min
• C. Respiratory rate 30/min
• D. Blood pressure 140/84 mm Hg

Correct answer: C

Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.

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