Nursing Elites

1. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

• A. Diazepam IV
• B. Lorazepam PO
• C. Diltiazem IV
• D. Clonazepam PO

Correct answer: A

Rationale: In the scenario described, where the client has been experiencing repeated tonic-clonic seizures over an extended period, the priority is to administer a medication that can rapidly terminate the seizures. Diazepam is the medication of choice for status epilepticus due to its rapid onset of action within 10 minutes when administered intravenously. Lorazepam is also an option, but it is typically administered intravenously as well. Diltiazem is a calcium channel blocker used for conditions like hypertension and angina, not for seizures. Clonazepam, although used for seizures, is not the ideal choice in this acute situation due to its slower onset of action compared to benzodiazepines like diazepam and lorazepam.

2. What is the expected finding in a patient with compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Localized swelling and redness
• C. Numbness and tingling
• D. Fever and infection

Correct answer: A

Rationale: In a patient with compartment syndrome, the expected finding includes unrelieved pain, pallor, and pulselessness. These are classic signs of compartment syndrome and indicate compromised blood flow and tissue perfusion, necessitating urgent intervention. Choices B, C, and D are incorrect because localized swelling and redness, numbness and tingling, as well as fever and infection, are not typical findings associated with compartment syndrome.

3. What precaution should be advised to patients following cataract surgery?

• A. Wear dark glasses while outdoors
• B. Use warm compresses
• C. Avoid NSAIDs
• D. Avoid bright lights

Correct answer: A

Rationale: Patients who have undergone cataract surgery should wear dark glasses when outdoors to shield their eyes from light exposure, which can be uncomfortable or harmful during the recovery period. Using warm compresses (choice B) is not typically recommended after cataract surgery as it's more relevant for certain eye conditions. Avoiding NSAIDs (choice C) is advised to prevent bleeding complications, but it is not directly related to eye protection post-surgery. While avoiding bright lights (choice D) is crucial, wearing dark glasses provides a practical solution to achieve this, making choice A the most appropriate precaution.

4. 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.

5. What is the priority intervention when continuous bubbling is observed in the water seal chamber of a chest tube?

• A. Check for an air leak
• B. Continue monitoring as it is not normal
• C. Replace the chest tube system
• D. Tighten the tube connections

Correct answer: A

Rationale: The correct answer is to 'Check for an air leak.' Continuous bubbling in the water seal chamber of a chest tube indicates an air leak, which can compromise the effectiveness of the chest tube in re-expanding the lung. Checking for an air leak is crucial to prevent respiratory complications. Choice B is incorrect because continuous bubbling is not normal and requires immediate intervention to address the air leak. Choice C is incorrect as replacing the entire chest tube system is not the initial priority when an air leak is suspected. Choice D is incorrect because tightening tube connections may not address the underlying issue of an air leak and should not be the initial action taken in this situation.

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