Nursing Elites

1. What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?

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

Correct answer: A

Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.

2. 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.

3. What is the first action when continuous bubbling is observed 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 system
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the first action should be to tighten the connections of the chest tube system. This step is crucial as it can often resolve an air leak causing continuous bubbling. Clamping the chest tube or replacing the chest tube system would not address the underlying issue of loose connections and may not be necessary. Continuing to monitor the chest tube without taking corrective action may lead to complications if the air leak is not addressed promptly.

4. What precaution should be advised to a patient following a cataract surgery?

• A. Wear dark glasses while outdoors
• B. Avoid NSAIDs
• C. Use warm compresses
• D. Apply cold packs

Correct answer: A

Rationale: Following cataract surgery, patients are advised to wear dark glasses while outdoors. This is crucial to protect the eyes from bright light and prevent complications such as excessive glare or discomfort. Choice B, avoiding NSAIDs, is not directly related to post-cataract surgery care. Choices C and D, using warm compresses and applying cold packs, are not typically part of the standard post-operative care for cataract surgery.

5. What is the priority lab value to monitor in a patient with HIV?

• A. CD4 T-cell count 180 cells/mm3
• B. White blood cell count 4,500/mm3
• C. Potassium levels 3.5-5.0 mEq/L
• D. Hemoglobin levels below 12g/dL

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV to assess the status of their immune system. A CD4 count of 180 cells/mm3 indicates severe immunocompromise and a high risk of opportunistic infections. This value is used to guide treatment decisions and assess the need for prophylaxis against specific infections. Choices B, C, and D are incorrect because monitoring white blood cell count, potassium levels, and hemoglobin levels, although important in HIV patients, are not as crucial as monitoring the CD4 T-cell count for assessing immune function and disease progression.

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