Nursing Elites

1. What is the initial nursing action for a patient with a chest tube found to have an air leak?

• A. Check the tube connections
• B. Replace the chest tube
• C. Remove and reinsert the chest tube
• D. Document the incident

Correct answer: A

Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.

2. What are the manifestations of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe nausea and vomiting
• C. Elevated blood pressure and bradycardia
• D. Decreased heart rate and altered pupil response

Correct answer: A

Rationale: The correct manifestations of increased intracranial pressure (IICP) include restlessness, confusion, and irritability. These symptoms are a result of the brain being under pressure inside the skull. Severe nausea and vomiting (Choice B) are more commonly associated with increased intracranial pressure in children. Elevated blood pressure and bradycardia (Choice C) are not typical manifestations of increased intracranial pressure; instead, hypertension and bradycardia may be seen in Cushing's reflex, which is a late sign of increased IICP. Decreased heart rate and altered pupil response (Choice D) are also not primary manifestations of increased intracranial pressure, although altered pupil response, like a non-reactive or dilated pupil, can be seen in some cases.

3. A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should not wash my hair prior to the procedure.
• B. I will receive a sedative 1 hour before the procedure.
• C. I should avoid eating prior to the procedure.
• D. I will be exposed to flashes of light during the procedure.

Correct answer: D

Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.

4. What is the first nursing action for a patient with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Increase fluids to prevent dehydration
• C. Obtain cardiac enzymes
• D. Get IV access and auscultate heart sounds

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority nursing action for a patient with chest pain and possible acute coronary syndrome. Nitroglycerin helps dilate the blood vessels, improve blood flow to the heart, and reduce cardiac workload. This action aims to relieve chest pain promptly and prevent further cardiac tissue damage. Increasing fluids is not the initial priority for a patient with chest pain and possible acute coronary syndrome. Obtaining cardiac enzymes is important for diagnosis but is not the first action in managing acute symptoms. Getting IV access and auscultating heart sounds are important interventions, but they come after administering sublingual nitroglycerin in the management of acute coronary syndrome.

5. What is the first medication to give to a patient with an allergic reaction causing wheezing?

• A. Albuterol 3 ml via nebulizer
• B. Methylprednisolone 100 mg IV
• C. Cromolyn 20 mg via nebulizer
• D. Aminophylline 500 mg IV

Correct answer: A

Rationale: The correct answer is A, Albuterol 3 ml via nebulizer. Albuterol is a fast-acting bronchodilator that helps relieve wheezing by relaxing the muscles in the airways, making it the first-line treatment for wheezing caused by bronchospasms in allergic reactions. Methylprednisolone (Choice B) is a corticosteroid used for its anti-inflammatory properties and is typically given after bronchodilators. Cromolyn (Choice C) is a mast cell stabilizer that is used for the prevention of asthma symptoms, not for immediate relief. Aminophylline (Choice D) is a bronchodilator that is less commonly used nowadays due to its narrow therapeutic window and potential for toxicity.

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