Nursing Elites

1. 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.

2. When providing discharge teaching to a patient who underwent cataract surgery, what should the patient avoid?

• A. Avoid NSAIDs
• B. Avoid bright lights
• C. Avoid alcohol
• D. Avoid phosphorus-rich foods

Correct answer: A

Rationale: The correct answer is to avoid NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding after cataract surgery due to their anticoagulant properties. Bright lights (choice B) are not contraindicated post-cataract surgery unless the patient experiences discomfort or sensitivity. Alcohol consumption (choice C) is generally not restricted after cataract surgery, but moderation is recommended. Phosphorus-rich foods (choice D) are not directly related to cataract surgery postoperative care.

3. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

• A. After stroking the lateral area of the foot, the client's toes contract and draw together
• B. After hip flexion, the client is unable to extend their leg completely without pain
• C. The client's voluntary movement is not coordinated
• D. The client reports pain and stiffness when flexing their neck

Correct answer: B

Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.

4. What does continuous bubbling in the water seal chamber of a chest tube indicate?

• A. An air leak
• B. A blockage in the chest tube
• C. Normal chest tube function
• D. Malfunction in the drainage system

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This bubbling occurs when air is escaping through the tube and entering the water seal chamber. Choice B, a blockage in the chest tube, is incorrect as continuous bubbling does not suggest a blockage. Choice C, normal chest tube function, is incorrect because continuous bubbling is not an expected finding in a properly functioning chest tube. Choice D, a malfunction in the drainage system, is incorrect as continuous bubbling specifically points towards an air leak, not a general malfunction.

5. What is the correct action when a patient reports cramping during enema administration?

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

Correct answer: A

Rationale: The correct action to take when a patient reports cramping during enema administration is to lower the height of the solution container. Lowering the height reduces the pressure and speed of the solution entering the rectum, alleviating cramping. Increasing the flow of the enema solution (Choice B) can worsen the discomfort. Stopping the procedure and removing the tubing (Choice C) is not necessary unless there are severe complications. Continuing the enema at a slower rate (Choice D) may not effectively address the immediate cramping issue and could still cause discomfort to the patient.

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