Nursing Elites

1. What intervention is needed when continuous bubbling is seen in the chest tube water seal chamber?

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

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate intervention is to tighten the connections of the chest tube system. This action can help resolve an air leak, which is often the cause of continuous bubbling in the water seal chamber. Clamping the chest tube (choice B) is not recommended as it can lead to a dangerous increase in pressure within the chest. Replacing the chest tube (choice C) is not the initial intervention unless there are other indications to do so. Simply monitoring the chest tube (choice D) without taking corrective action will not address the underlying issue of the air leak causing continuous bubbling.

2. What are the expected symptoms in a patient with 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: A thrombotic stroke typically presents with a gradual loss of function on one side of the body. This gradual onset distinguishes it from a hemorrhagic stroke, which often manifests with sudden and severe symptoms like loss of consciousness (choice B), severe headache and confusion (choice C), or loss of sensation in the affected limb (choice D). Therefore, choices B, C, and D are not typically associated with thrombotic strokes.

3. A patient who received an enema reports abdominal cramping. What should the nurse do?

• A. Increase the flow of the enema solution
• B. Lower the height of the enema solution container
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

4. A patient with chronic kidney disease may require dietary restrictions. Which of the following diets should the healthcare provider prescribe?

• A. Low sodium diet
• B. Potassium restricted diet
• C. High phosphorus diet
• D. High protein diet

Correct answer: B

Rationale: Patients with chronic kidney disease often require a potassium-restricted diet to help manage their electrolyte levels. Excessive potassium intake can be harmful to individuals with compromised kidney function. While monitoring sodium intake is also important for these patients, a low sodium diet is not specifically indicated in the question. High phosphorus diet and high protein diet are not recommended for individuals with chronic kidney disease as they can further stress the kidneys and worsen the condition.

5. What intervention should the nurse take for a patient experiencing delayed wound healing?

• A. Monitor serum albumin levels
• B. Apply a dry dressing
• C. Administer antibiotics
• D. Change the wound dressing every 8 hours

Correct answer: A

Rationale: Monitoring serum albumin levels is crucial for patients with delayed wound healing. Low albumin levels indicate a lack of protein, which can impair the healing process and increase the risk of infection. By monitoring serum albumin levels, the nurse can assess the patient's nutritional status and make necessary interventions to promote wound healing. Applying a dry dressing (Choice B) may be appropriate depending on the wound characteristics, but it does not address the underlying cause of delayed healing. Administering antibiotics (Choice C) is not the first-line intervention for delayed wound healing unless there is an active infection present. Changing the wound dressing every 8 hours (Choice D) may lead to excessive disruption of the wound bed and hinder the healing process.

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