Nursing Elites

1. What should the nurse do if a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the solution container
• B. Increase the flow of the enema solution
• C. Stop the procedure and remove the tubing
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the solution container. This adjustment can help alleviate the cramping by reducing the speed and pressure of the solution entering the colon. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in extreme cases but is not the initial step. Continuing the enema at a slower rate (Choice D) may not effectively address the cramping, making it less optimal than lowering the height of the solution container.

2. What intervention should the nurse take for a patient experiencing delayed wound healing?

• A. Monitor serum albumin levels
• B. Apply a dry dressing
• C. Administer antibiotics
• D. Change the wound dressing every 8 hours

Correct answer: A

Rationale: Monitoring serum albumin levels is crucial for patients with delayed wound healing. Low albumin levels indicate a lack of protein, which can impair the healing process and increase the risk of infection. By monitoring serum albumin levels, the nurse can assess the patient's nutritional status and make necessary interventions to promote wound healing. Applying a dry dressing (Choice B) may be appropriate depending on the wound characteristics, but it does not address the underlying cause of delayed healing. Administering antibiotics (Choice C) is not the first-line intervention for delayed wound healing unless there is an active infection present. Changing the wound dressing every 8 hours (Choice D) may lead to excessive disruption of the wound bed and hinder the healing process.

3. What intervention is needed for continuous bubbling 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 system
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: The correct intervention for continuous bubbling in the chest tube water seal chamber is to tighten the connections of the chest tube system. Continuous bubbling indicates an air leak in the system, and tightening the connections can help resolve this issue. Clamping the chest tube (Choice B) is not appropriate and can lead to complications by obstructing the drainage system. Similarly, replacing the entire chest tube system (Choice C) may not be necessary if the issue can be resolved by tightening the connections. Continuing to monitor the chest tube (Choice D) without taking action to address the continuous bubbling may delay necessary interventions to prevent complications.

4. A client has a Transient Ischemic Attack (TIA). What should the nurse teach?

• A. Avoid eating within 3 hours of bedtime
• B. Consume liquids between meals
• C. Eat large meals to increase caloric intake
• D. Avoid liquids to prevent aspiration

Correct answer: A

Rationale: The correct answer is A: Avoid eating within 3 hours of bedtime. For a client with a Transient Ischemic Attack (TIA), it is crucial to avoid eating within 3 hours of bedtime to reduce reflux that can worsen symptoms. Choice B is incorrect because consuming liquids between meals is not specifically related to managing TIA. Choice C is incorrect as eating large meals may not be recommended, especially if the client needs to watch their caloric intake. Choice D is incorrect because avoiding liquids entirely can lead to dehydration and is not a standard recommendation for TIA management.

5. What dietary modifications are recommended for a patient with pre-dialysis kidney disease?

• A. Limit phosphorus intake to 700 mg/day
• B. Increase sodium intake to 3 g/day
• C. Restrict protein intake to 0.55-0.60 g/kg/day
• D. Eat three large meals per day

Correct answer: A

Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. Patients with pre-dialysis kidney disease should limit phosphorus intake to prevent further kidney damage. Excessive phosphorus can lead to mineral and bone disorders. Choice B is incorrect because increasing sodium intake is not recommended in pre-dialysis kidney disease. Choice C is incorrect as protein restriction is a common recommendation in advanced kidney disease, not pre-dialysis. Choice D is incorrect as eating three large meals per day is not a specific dietary modification for pre-dialysis kidney disease.

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