Nursing Elites

1. What does continuous bubbling in the water seal chamber of a chest tube indicate?

• A. An air leak
• B. Normal chest tube function
• C. A blockage in the chest tube
• D. A malfunction in the drainage system

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This bubbling occurs when air leaks from the patient's pleural space into the chest tube system. It is essential to address this issue promptly to prevent complications like a pneumothorax. Choices B, C, and D are incorrect because continuous bubbling in the water seal chamber is not indicative of normal chest tube function, a blockage in the chest tube, or a malfunction in the drainage system.

2. 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.

3. 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.

4. What is the priority lab value to monitor in a patient with HIV?

• A. CD4 T-cell count 180 cells/mm3
• B. White blood cell count 4,500/mm3
• C. Potassium levels 3.5-5.0 mEq/L
• D. Hemoglobin levels below 12g/dL

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV to assess the status of their immune system. A CD4 count of 180 cells/mm3 indicates severe immunocompromise and a high risk of opportunistic infections. This value is used to guide treatment decisions and assess the need for prophylaxis against specific infections. Choices B, C, and D are incorrect because monitoring white blood cell count, potassium levels, and hemoglobin levels, although important in HIV patients, are not as crucial as monitoring the CD4 T-cell count for assessing immune function and disease progression.

5. What is the priority action when a healthcare professional misreads a glucose reading and administers excess insulin?

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

Correct answer: C

Rationale: The priority action when a healthcare professional misreads a glucose reading and administers excess insulin is to monitor for hypoglycemia. Excess insulin can lead to dangerously low blood sugar levels (hypoglycemia), which can result in serious complications. Monitoring for hypoglycemia allows for timely identification and intervention to prevent harm. Administering IV glucose may be necessary if hypoglycemia occurs. Monitoring for hyperglycemia is not the priority in this situation, as excess insulin would lower blood sugar levels. Documenting the incident is important for reporting and quality improvement purposes but should not take precedence over ensuring patient safety by monitoring for hypoglycemia.

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