Nursing Elites

1. 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.

2. 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.

3. What should be done when continuous bubbling is observed 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 to monitor the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate action is to tighten the connections of the chest tube system. This may resolve an air leak that is causing the continuous bubbling. Option B, replacing the chest tube system, is not the initial step to take and is considered more invasive. Clamping the chest tube (option C) can lead to complications and should not be done unless instructed by a healthcare provider. Continuing to monitor the chest tube (option D) without taking any corrective action may delay necessary interventions.

4. A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?

• A. Lidocaine
• B. Adenosine
• C. Atropine
• D. Verapamil

Correct answer: C

Rationale: The correct answer is C: Atropine. The client's presentation of bradycardia, diaphoresis, and chest pain indicates reduced cardiac output, requiring intervention to increase the heart rate. Atropine is used to treat bradycardia by blocking cardiac muscarinic receptors, thus inhibiting the parasympathetic nervous system. Lidocaine (Choice A) is used for ventricular arrhythmias, not bradycardia. Adenosine (Choice B) is used for supraventricular tachycardia, not bradycardia. Verapamil (Choice D) is a calcium channel blocker used for certain arrhythmias and hypertension, but not for increasing heart rate in bradycardia.

5. What is the first medication to administer to a patient experiencing wheezing due to an allergic reaction?

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

Correct answer: A

Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-choice medication for wheezing due to its fast-acting bronchodilatory effect, which helps in relieving the symptoms quickly. Choice B, Methylprednisolone 100 mg IV, is a corticosteroid used for its anti-inflammatory effects and would be beneficial in reducing inflammation in allergic reactions but is not the first-line treatment for wheezing. Choice C, Cromolyn 20 mg via nebulizer, is a mast cell stabilizer used to prevent asthma attacks but is not the immediate treatment for wheezing during an allergic reaction. Choice D, Aminophylline 500 mg IV, is a bronchodilator but is not typically the initial medication of choice for wheezing in an allergic reaction.

Similar Questions