Nursing Elites

1. 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.

2. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. Lie on your left side.
• B. Lie on your right side.
• C. Increase your fluid intake.
• D. Decrease your fluid intake.

Correct answer: B

Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.

3. What should be monitored for in a patient with compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Localized redness and swelling
• C. Fever and infection
• D. Muscle weakness and fatigue

Correct answer: A

Rationale: Correct Answer: A. Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome that indicate inadequate blood flow to the affected area. These symptoms are crucial to monitor as they signify a medical emergency requiring immediate intervention. Choices B, C, and D are incorrect because they do not align with the typical manifestations of compartment syndrome. Localized redness and swelling may be present but are not the primary indicators. Fever and infection are also not specific to compartment syndrome, and muscle weakness and fatigue are not typically prominent symptoms of this condition.

4. A patient who received an enema reports abdominal cramping. What should the nurse do?

• A. Increase the flow of the enema solution
• B. Lower the height of the enema solution container
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

5. What intervention is needed 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, the appropriate intervention is to tighten the connections of the chest tube system. This action can help resolve an air leak, which is often the cause of continuous bubbling in the water seal chamber. Clamping the chest tube (choice B) is not recommended as it can lead to a dangerous increase in pressure within the chest. Replacing the chest tube (choice C) is not the initial intervention unless there are other indications to do so. Simply monitoring the chest tube (choice D) without taking corrective action will not address the underlying issue of the air leak causing continuous bubbling.

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