Nursing Elites

1. What is the priority action if a patient experiences abdominal 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: During enema administration, if a patient experiences abdominal cramping, the priority action is to lower the height of the solution container. This adjustment can help relieve abdominal cramping by reducing the flow rate of the enema, making it more comfortable for the patient. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in some cases of severe discomfort or complications, but adjusting the height of the solution container should be the initial response. Continuing the enema at a slower rate (Choice D) may not address the immediate need to alleviate the cramping.

2. A nurse is caring for a client with rheumatoid arthritis who has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Weight loss
• B. Hypoglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: C

Rationale: The correct answer is C, 'Hypertension.' Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium retention and potassium loss, leading to increased blood pressure. Weight loss (choice A) is not a common adverse effect of prednisone; in fact, weight gain is more common. Hypoglycemia (choice B) is not typically associated with prednisone use; instead, hyperglycemia is a common concern. Hyperkalemia (choice D) is also unlikely with prednisone use; instead, hypokalemia is a potential electrolyte imbalance.

3. What should the healthcare provider do first when a patient is admitted with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority intervention when a patient presents with chest pain and suspected acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. It is crucial to address the pain and potential ischemia promptly to prevent further cardiac tissue damage. Getting IV access, auscultating heart sounds, and obtaining cardiac enzymes are important assessments and interventions, but administering nitroglycerin takes precedence in managing acute coronary syndrome.

4. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?

• A. Keep a padded tongue depressor near the bedside
• B. Place a pillow under the client's head during a seizure
• C. Administer diazepam intravenously at the onset of seizures
• D. Position the client on their side during a seizure

Correct answer: D

Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.

5. What intervention is needed for continuous bubbling 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: The correct intervention for continuous bubbling in the chest tube water seal chamber is to tighten the connections of the chest tube system. Continuous bubbling indicates an air leak in the system, and tightening the connections can help resolve this issue. Clamping the chest tube (Choice B) is not appropriate and can lead to complications by obstructing the drainage system. Similarly, replacing the entire chest tube system (Choice C) may not be necessary if the issue can be resolved by tightening the connections. Continuing to monitor the chest tube (Choice D) without taking action to address the continuous bubbling may delay necessary interventions to prevent complications.

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