Nursing Elites

1. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?

• A. Breath sounds
• B. Temperature
• C. Blood pressure
• D. Creatine kinase

Correct answer: A

Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.

2. What teaching should be provided after cataract surgery?

• A. Avoid NSAIDs
• B. Wear dark glasses outdoors
• C. Creamy white drainage is normal
• D. Avoid bright lights

Correct answer: A

Rationale: The correct teaching that should be provided after cataract surgery is to avoid NSAIDs. NSAIDs should be avoided to prevent bleeding, especially in the eye area. While wearing dark glasses outdoors is important to protect the eyes, it is not the most critical teaching after cataract surgery. Creamy white drainage being normal is not relevant to post-cataract surgery teaching. Avoiding bright lights is generally recommended for patients with certain eye conditions but is not a specific teaching point after cataract surgery.

3. What intervention is needed when continuous bubbling is observed 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 system
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the correct intervention is to tighten the connections of the chest tube system. This can help resolve an air leak that is causing the continuous bubbling. Clamping the chest tube or replacing the entire chest tube system are not appropriate interventions in this scenario. Clamping the tube can lead to a dangerous buildup of pressure, while replacing the chest tube system may not be necessary if the issue can be resolved by simply tightening the connections. Continuing to monitor the chest tube without taking corrective action may lead to complications associated with the air leak.

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. A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?

• A. Lidocaine
• B. Adenosine
• C. Atropine
• D. Verapamil

Correct answer: C

Rationale: The correct answer is C: Atropine. The client's presentation of bradycardia, diaphoresis, and chest pain indicates reduced cardiac output, requiring intervention to increase the heart rate. Atropine is used to treat bradycardia by blocking cardiac muscarinic receptors, thus inhibiting the parasympathetic nervous system. Lidocaine (Choice A) is used for ventricular arrhythmias, not bradycardia. Adenosine (Choice B) is used for supraventricular tachycardia, not bradycardia. Verapamil (Choice D) is a calcium channel blocker used for certain arrhythmias and hypertension, but not for increasing heart rate in bradycardia.

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