Nursing Elites

1. How does hyponatremia place the patient at risk?

• A. Seizures
• B. Fatigue
• C. Cardiac dysrhythmias
• D. Muscle weakness

Correct answer: C

Rationale: Hyponatremia places the patient at risk for cardiac dysrhythmias. While hyponatremia can lead to seizures due to cerebral edema caused by fluid imbalance, the most immediate and life-threatening risk is cardiac dysrhythmias. Low sodium levels can disrupt the heart's electrical activity, potentially leading to fatal arrhythmias. Although fatigue and muscle weakness are symptoms of hyponatremia, cardiac dysrhythmias pose the most critical concern as they can have severe consequences.

2. What intervention is needed for a patient with a chest tube and an air leak?

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

Correct answer: A

Rationale: The correct intervention for a patient with a chest tube and an air leak is to tighten the connections of the chest tube system. This step helps prevent air leaks and ensures the proper functioning of the chest tube. Choice B, replacing the chest tube, is not necessary as tightening the connections should be attempted first. Clamping the chest tube (Choice C) is not recommended as it can lead to complications by obstructing the drainage system. Continuing to monitor the chest tube (Choice D) without taking action may result in worsening of the air leak. Therefore, the priority intervention is to tighten the connections of the chest tube system.

3. What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?

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

Correct answer: A

Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.

4. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?

• A. Apply an ice pack directly to the affected area
• B. Immobilize the affected extremity with a splint
• C. Place a tourniquet above and below the affected area
• D. Elevate the affected extremity

Correct answer: B

Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.

5. What is the priority intervention for a patient with possible acute coronary syndrome?

• A. Administer nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with possible acute coronary syndrome as it helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart. This intervention is crucial in managing acute coronary syndrome and should be given promptly. Getting IV access may be necessary, but administering nitroglycerin takes precedence to alleviate symptoms and prevent further heart damage. Auscultating heart sounds and administering aspirin are important aspects of the assessment and treatment plan, but they are not the priority interventions in the acute phase of suspected acute coronary syndrome.

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