Nursing Elites

1. What should be done if 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: When a patient experiences abdominal cramping during enema administration, the appropriate action is to lower the height of the enema solution container. This adjustment helps alleviate the cramping by reducing the pressure of the solution entering the colon. Stopping the procedure and removing the tubing (Choice B) is not necessary unless there are other complications. Continuing the enema at a slower rate (Choice C) may not address the immediate discomfort caused by cramping. Increasing the flow of the enema solution (Choice D) can exacerbate the cramping and should be avoided.

2. What should be the priority action when a patient is admitted with chest pain from acute coronary syndrome?

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

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action in treating chest pain associated with acute coronary syndrome as it helps to dilate blood vessels, improve blood flow to the heart, and reduce cardiac tissue damage. Administering nitroglycerin is crucial in managing the symptoms and potential complications of acute coronary syndrome. Obtaining IV access (Choice B) is important for administering medications and fluids but does not address the immediate symptom of chest pain. Checking cardiac enzymes (Choice C) and administering aspirin (Choice D) are essential steps in the management of acute coronary syndrome, but they should follow the administration of nitroglycerin to address the immediate symptom and improve blood flow to the heart.

3. A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should not wash my hair prior to the procedure.
• B. I will receive a sedative 1 hour before the procedure.
• C. I should avoid eating prior to the procedure.
• D. I will be exposed to flashes of light during the procedure.

Correct answer: D

Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.

4. What are the expected signs of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe headache and confusion
• C. Elevated blood pressure and bradycardia
• D. Bradycardia and altered pupil response

Correct answer: A

Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.

5. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?

• A. Immunosuppressant medications need to be taken for up to 1 year
• B. Shortness of breath might be an indication of transplant rejection
• C. The surgical site will heal in 3 to 4 weeks after surgery
• D. Begin 45 minutes of moderate aerobic exercise per day following discharge

Correct answer: B

Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.

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