Nursing Elites

1. 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.

2. What is the preferred electrical intervention for a patient with ventricular tachycardia with a pulse?

• A. Synchronized cardioversion
• B. Defibrillation
• C. Pacing
• D. Medication administration

Correct answer: A

Rationale: The correct answer is A: Synchronized cardioversion. In ventricular tachycardia with a pulse, synchronized cardioversion is the preferred electrical intervention. Synchronized cardioversion is used to treat tachyarrhythmias where there is a pulse present. Defibrillation (choice B) is used in emergencies for pulseless ventricular tachycardia or ventricular fibrillation. Pacing (choice C) is more suitable for bradycardias or certain conduction abnormalities. Medication administration (choice D) may be used in stable cases or as an adjunct to other treatments, but synchronized cardioversion is the primary intervention for ventricular tachycardia with a pulse.

3. What is the priority intervention when 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: The correct answer is to lower the height of the enema solution container. This action can help relieve abdominal cramping by slowing the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is not the priority as adjusting the height of the container can often resolve the issue without needing to stop the procedure completely. Choice C, continuing the enema at a slower rate, may not address the immediate discomfort experienced by the patient. Choice D, increasing the flow of the enema solution, can exacerbate the cramping and should be avoided.

4. What is the purpose of an escharotomy?

• A. To relieve pressure and improve circulation in burn injuries
• B. To reduce pain in the affected area
• C. To remove necrotic tissue from a wound
• D. To prevent infection from spreading

Correct answer: A

Rationale: An escharotomy is performed to relieve pressure and improve circulation in areas affected by deep burns. This procedure helps prevent complications such as compartment syndrome by releasing the constricting eschar. Choice B is incorrect because while pain relief may be a secondary outcome of the procedure, the primary purpose is to address pressure and circulation issues. Choice C is incorrect as an escharotomy specifically focuses on releasing pressure, not removing necrotic tissue. Choice D is incorrect as the primary goal of an escharotomy is not to prevent infection but rather to address the immediate issues related to deep burn injuries.

5. What is the first intervention for a patient admitted with unstable angina?

• A. Administer nitroglycerin
• B. Obtain cardiac enzymes
• C. Start IV fluids
• D. Monitor for chest pain

Correct answer: A

Rationale: The correct first intervention for a patient admitted with unstable angina is to administer nitroglycerin. Nitroglycerin helps to relieve chest pain by dilating blood vessels and increasing blood flow to the heart, thereby reducing cardiac workload. This intervention aims to alleviate symptoms and prevent further cardiac damage. Obtaining cardiac enzymes (Choice B) is important for diagnosing a myocardial infarction but is not the initial intervention for unstable angina. Starting IV fluids (Choice C) may be indicated in specific cases like hypovolemia but is not the primary intervention for unstable angina. Monitoring for chest pain (Choice D) is essential but taking action to alleviate the pain, like administering nitroglycerin, is the primary focus in the initial management of unstable angina.

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