Nursing Elites

1. What intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Replace the chest tube system
• C. Clamp 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 step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.

2. What are the expected findings in a patient experiencing hypokalemia?

• A. Flattened T waves on an ECG
• B. Elevated ST segments
• C. Prominent U waves
• D. Bradycardia

Correct answer: A

Rationale: The correct answer is A: Flattened T waves on an ECG. Hypokalemia is characterized by flattened T waves on an ECG, which is an early indicator of low potassium levels. Elevated ST segments (Choice B) are associated with conditions like myocardial infarction, not hypokalemia. Prominent U waves (Choice C) are typically seen in hypokalemia, but flattened T waves are more specific. Bradycardia (Choice D) can be a manifestation of severe hypokalemia but is not as specific as flattened T waves on an ECG.

3. A patient with hypokalemia is being monitored. What should the nurse assess for?

• A. Muscle weakness
• B. Flattened T waves
• C. Checking deep tendon reflexes
• D. Seizures

Correct answer: A

Rationale: Corrected Question: A patient with hypokalemia is being monitored. What should the nurse assess for? Corrected Choice A: Muscle weakness Corrected Choice B: Flattened T waves Corrected Choice C: Checking deep tendon reflexes Corrected Choice D: Seizures Rationale: Hypokalemia is associated with muscle weakness due to the effect of low potassium levels on muscle function. Flattened T waves on an ECG are characteristic of hypokalemia but are not a direct assessment for the patient's condition. Checking deep tendon reflexes and seizures are not primary symptoms associated with hypokalemia, making them less relevant for monitoring a patient with this electrolyte imbalance.

4. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?

• A. Breath sounds
• B. Temperature
• C. Blood pressure
• D. Creatine kinase

Correct answer: A

Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.

5. What is the priority action when the nurse administers insulin for a misread blood glucose reading?

• A. Monitor for signs of hypoglycemia
• B. Monitor for hyperglycemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.

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