Nursing Elites

1. A patient is admitted with an air leak in a chest tube system. What action should the nurse take?

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

Correct answer: A

Rationale: When caring for a patient with an air leak in the chest tube system, the nurse should tighten the connections of the chest tube system. This action can help resolve the air leak by ensuring there are no loose connections or leaks in the system. Continuing to monitor the patient (Choice B) is important, but addressing the air leak is a priority. Replacing the chest tube system (Choice C) may not be necessary if tightening the connections resolves the issue. Clamping the chest tube (Choice D) is not appropriate as it can lead to tension pneumothorax.

2. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

• A. Distended, board-like abdomen
• B. WBC count of 15,000/mm3
• C. Rebound tenderness over McBurney's point
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen should be reported to the provider immediately because it indicates peritonitis, a serious complication of appendicitis resulting from a ruptured appendix. Option B, an elevated WBC count, may indicate infection but is not as urgent as a board-like abdomen. Option C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate immediate life-threatening complications. Option D, a slightly elevated temperature, is not as concerning as a distended, board-like abdomen.

3. A nurse is caring for a client with rheumatoid arthritis who has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Weight loss
• B. Hypoglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: C

Rationale: The correct answer is C, 'Hypertension.' Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium retention and potassium loss, leading to increased blood pressure. Weight loss (choice A) is not a common adverse effect of prednisone; in fact, weight gain is more common. Hypoglycemia (choice B) is not typically associated with prednisone use; instead, hyperglycemia is a common concern. Hyperkalemia (choice D) is also unlikely with prednisone use; instead, hypokalemia is a potential electrolyte imbalance.

4. What should be done when continuous bubbling is observed 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 to monitor the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate action is to tighten the connections of the chest tube system. This may resolve an air leak that is causing the continuous bubbling. Option B, replacing the chest tube system, is not the initial step to take and is considered more invasive. Clamping the chest tube (option C) can lead to complications and should not be done unless instructed by a healthcare provider. Continuing to monitor the chest tube (option D) without taking any corrective action may delay necessary interventions.

5. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?

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

Correct answer: B

Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.

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