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 is the priority intervention for a patient with possible acute coronary syndrome?

• A. Administer nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with possible acute coronary syndrome as it helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart. This intervention is crucial in managing acute coronary syndrome and should be given promptly. Getting IV access may be necessary, but administering nitroglycerin takes precedence to alleviate symptoms and prevent further heart damage. Auscultating heart sounds and administering aspirin are important aspects of the assessment and treatment plan, but they are not the priority interventions in the acute phase of suspected acute coronary syndrome.

3. What intervention is required when continuous bubbling is seen 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
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, tightening the connections of the chest tube system is the appropriate intervention. This action can often resolve an air leak, which is the common cause of continuous bubbling. Clamping the chest tube or replacing it is not recommended as the first-line intervention because it may lead to complications or unnecessary tube changes. Continuing to monitor the chest tube without addressing the air leak would delay necessary corrective action, potentially causing respiratory compromise in the patient. Therefore, tightening the connections of the chest tube system is the most suitable initial step to manage continuous bubbling in the water seal chamber.

4. A patient with ventricular tachycardia and a pulse needs electrical intervention. What is the appropriate action?

• A. Defibrillation
• B. Synchronized cardioversion
• C. Pacing
• D. Medication administration

Correct answer: B

Rationale: For a patient with ventricular tachycardia and a pulse, the appropriate action is synchronized cardioversion. Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing is typically used for bradycardias. Medication administration may be considered in stable ventricular tachycardia cases but electrical intervention is preferred for immediate correction in this scenario.

5. What is the initial nursing action for a patient with a chest tube found to have an air leak?

• A. Check the tube connections
• B. Replace the chest tube
• C. Remove and reinsert the chest tube
• D. Document the incident

Correct answer: A

Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.

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