Nursing Elites

1. What is the priority action if a patient experiences hypoglycemia after an insulin dose?

• A. Check the patient's blood glucose level
• B. Administer IV dextrose
• C. Document the incident
• D. Continue monitoring the patient

Correct answer: A

Rationale: The priority action when a patient experiences hypoglycemia after an insulin dose is to check the patient's blood glucose level. This is crucial to confirm hypoglycemia before initiating any treatment. While administering IV dextrose may be necessary if the patient's blood glucose level is critically low, confirming hypoglycemia is essential to guide appropriate interventions. Documenting the incident is important for documentation purposes but is not the immediate priority when the patient's safety is at risk. Continuing to monitor the patient is essential, but it should follow the confirmation and initial management of hypoglycemia.

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

• A. An air leak
• B. Drainage in the chest tube
• C. A blocked chest tube
• D. Normal chest tube function

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This signifies that air is escaping from the patient's pleural space into the chest tube system rather than being evacuated properly. An air leak can lead to lung collapse or pneumothorax and requires immediate attention. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because continuous bubbling does not indicate normal chest tube function, drainage in the chest tube, or a blocked chest tube.

3. What lab value is a priority in monitoring a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Hemoglobin levels
• C. Serum albumin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it reflects the status of the immune system. A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise and an increased risk of opportunistic infections. This value guides the initiation of prophylaxis for infections and the timing of antiretroviral therapy initiation. Choices B, C, and D are not the priority lab values in monitoring patients with HIV. Hemoglobin levels primarily assess for anemia, serum albumin levels reflect nutritional status, and white blood cell count is more generalized and may not specifically indicate the severity of immunocompromise in HIV patients.

4. What is the priority nursing action when a patient with chest pain presents with possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Obtain IV access
• C. Check the patient's cardiac enzymes
• D. Administer aspirin

Correct answer: A

Rationale: The priority nursing action when a patient with chest pain presents with possible acute coronary syndrome is to administer sublingual nitroglycerin. Sublingual nitroglycerin helps dilate blood vessels, reducing cardiac workload, and improving blood supply to the heart muscle, thus relieving pain and enhancing blood flow to the heart. While obtaining IV access is important for administering medications and fluids, it is not the priority over addressing pain and improving blood flow. Checking the patient's cardiac enzymes is crucial for diagnosis and ongoing management but not the immediate priority when the patient is in pain. Administering aspirin is also a vital intervention in acute coronary syndrome, but in this scenario, it is not the priority action compared to providing immediate pain relief and enhancing blood flow to the heart.

5. What is the first medication to give for wheezing due to an allergic reaction?

• A. Albuterol via nebulizer
• B. Cromolyn 20 mg via nebulizer
• C. Methylprednisolone 100 mg IV
• D. Aminophylline 500 mg IV

Correct answer: A

Rationale: Albuterol is the first-line medication for treating wheezing due to an allergic reaction. Albuterol is a short-acting beta-agonist that helps relieve bronchospasm quickly. Cromolyn is more commonly used for the prevention of asthma symptoms rather than for acute treatment. Methylprednisolone and aminophylline are not the first-line medications for acute wheezing due to an allergic reaction.

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