Nursing Elites

1. What are the expected symptoms of a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Severe headache and confusion
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' In a thrombotic stroke, a clot blocks a cerebral artery, leading to a gradual onset of symptoms such as weakness, numbness, or paralysis on one side of the body. Choice B, 'Sudden loss of consciousness,' is more characteristic of a hemorrhagic stroke. Choice C, 'Severe headache and confusion,' are often associated with subarachnoid hemorrhage rather than thrombotic stroke. Choice D, 'Loss of sensation in the affected limb,' is not a typical symptom pattern for a thrombotic stroke, which usually presents with motor deficits.

2. What is the most likely cause of continuous bubbling in the water seal chamber of a chest tube?

• A. An air leak
• B. A blockage in the chest tube
• C. Normal chest tube function
• D. Drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube usually indicates an air leak. An air leak can disrupt the negative pressure required for the chest tube to function properly, leading to inadequate drainage and potential complications. A blockage in the chest tube would typically result in decreased or absent drainage rather than continuous bubbling. Normal chest tube function does not involve continuous bubbling in the water seal chamber. Drainage from the chest tube may lead to fluid moving into the drainage system, but it would not cause continuous bubbling in the water seal chamber.

3. What are the adverse effects of radiation after a mastectomy?

• A. S3 heart sound, fatigue
• B. Pulselessness in the affected extremity
• C. SOB and JVD
• D. Localized pain, swelling, erythema

Correct answer: A

Rationale: The correct answer is A: S3 heart sound, fatigue. Radiation after a mastectomy can lead to fatigue and symptoms of heart failure, such as the presence of an S3 heart sound. Choices B, C, and D are incorrect. Pulselessness in the affected extremity would be more relevant to vascular complications, shortness of breath (SOB) and jugular venous distention (JVD) could indicate cardiac or respiratory issues unrelated to radiation, and localized pain, swelling, and erythema are more characteristic of a local inflammatory response rather than the systemic effects of radiation post-mastectomy.

4. What should be done if a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the appropriate action is to lower the height of the enema solution container. This adjustment helps alleviate the cramping by reducing the pressure of the solution entering the colon. Stopping the procedure and removing the tubing (Choice B) is not necessary unless there are other complications. Continuing the enema at a slower rate (Choice C) may not address the immediate discomfort caused by cramping. Increasing the flow of the enema solution (Choice D) can exacerbate the cramping and should be avoided.

5. What lab value should be prioritized in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Hemoglobin levels
• C. Serum albumin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. In a patient with HIV, monitoring the CD4 T-cell count is crucial as it reflects the status of the immune system. A CD4 T-cell count below 200 cells/mm3 indicates severe immunocompromise and risk of opportunistic infections. Hemoglobin levels (choice B) are important for assessing anemia but do not directly reflect the immune status in HIV patients. Serum albumin levels (choice C) are indicators of nutritional status and inflammation, not specific to HIV disease progression. White blood cell count (choice D) may fluctuate due to various conditions and is not as specific as the CD4 T-cell count in assessing HIV progression.

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