Nursing Elites

1. A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

• A. Contact precautions
• B. Airborne precautions
• C. Droplet precautions
• D. Protective environment

Correct answer: B

Rationale: Tuberculosis is spread through small droplets measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has TB under airborne precautions to prevent the spread of microbes. Choice A, contact precautions, are used for diseases spread by direct or indirect contact. Choice C, droplet precautions, are for diseases spread by larger droplets. Choice D, protective environment, is used for immunocompromised clients to protect them from environmental pathogens.

2. What intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Replace the chest tube system
• C. Clamp 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 appropriate intervention is to tighten the connections of the chest tube system. This step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.

3. What should the nurse do for a patient experiencing abdominal cramping during enema administration?

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

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the solution. Choice B, stopping the procedure and removing the tubing, is incorrect as it is too drastic and may not address the cramping. Choice C, continuing the enema at a slower rate, may exacerbate the cramping if the flow rate is still too high. Choice D, increasing the flow of the enema solution, would worsen the cramping and is not the appropriate intervention.

4. What is the priority intervention for a patient with unstable angina?

• A. Administer nitroglycerin
• B. Establish IV access
• C. Auscultate heart sounds
• D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.

5. A client has a right-sided pneumothorax, and a chest tube is inserted. Which finding indicates that the chest drainage system is functioning correctly?

• A. Gentle bubbling in the suction chamber
• B. Crepitus around the insertion site
• C. Constant bubbling in the water seal chamber
• D. Absence of breath sounds on the right side

Correct answer: A

Rationale: In a chest drainage system, gentle bubbling in the suction chamber indicates proper functioning, showing that the system is connected and working effectively to remove air or fluid from the pleural space. Crepitus around the insertion site (Choice B) suggests subcutaneous emphysema, not chest tube functionality. Constant bubbling in the water seal chamber (Choice C) indicates an air leak. Absence of breath sounds on the right side (Choice D) is indicative of the pneumothorax, not the chest tube function.

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