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 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.

3. A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?

• A. Teach the client to report findings of IV extravasation
• B. Evaluate the patency of the IV
• C. Consult with the pharmacist about the prescription
• D. Verify the prescription with the provider

Correct answer: D

Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.

4. What is the priority action when the nurse administers insulin for a misread blood glucose reading?

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

Correct answer: A

Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.

5. What is an escharotomy and when is it performed?

• A. A surgical incision to release pressure in burn injuries
• B. A procedure to remove dead tissue from wounds
• C. An incision to improve circulation in tight skin after burns
• D. A procedure to remove excess fluid from the chest

Correct answer: A

Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.

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