Nursing Elites

1. What should the nurse do 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 nurse should tighten the connections of the chest tube system. This action can often resolve an air leak causing the continuous bubbling. Clamping the chest tube or replacing it would not address the underlying issue of an air leak and may lead to complications. Continuing to monitor the chest tube without taking corrective action may result in the deterioration of the patient's condition.

2. 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.

3. What is the priority action for a patient with chest pain from acute coronary syndrome?

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

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps dilate the blood vessels, reducing the workload of the heart and improving blood flow to the heart muscle, which is crucial in the management of acute coronary syndrome. Checking cardiac enzymes (choice B) is important for diagnosing a heart attack but is not the priority over providing immediate relief to the patient's chest pain. Administering aspirin (choice C) is also important in acute coronary syndrome to prevent further clot formation, but it is not the priority action for immediate pain relief. Obtaining IV access (choice D) is necessary for administering medications or fluids; however, in this scenario, providing sublingual nitroglycerin for prompt pain relief takes precedence.

4. What is the purpose of an escharotomy in burn management?

• A. To relieve pressure and improve circulation in burn injuries
• B. To remove necrotic tissue from a wound
• C. To prevent infection in burn injuries
• D. To remove excess fluid from burn wounds

Correct answer: A

Rationale: An escharotomy is performed to relieve pressure in areas affected by deep burns and improve circulation. This procedure involves making incisions through the eschar (burned and dead tissue) to release constricting tissue and allow for the return of blood flow. Choice B is incorrect because the removal of necrotic tissue is typically done through debridement, not escharotomy. Choice C is incorrect because preventing infection in burn injuries is usually achieved through proper wound care and antibiotic therapy, not escharotomy. Choice D is incorrect because removing excess fluid from burn wounds is managed through methods like fluid resuscitation and monitoring, not escharotomy.

5. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?

• A. Keep a padded tongue depressor near the bedside
• B. Place a pillow under the client's head during a seizure
• C. Administer diazepam intravenously at the onset of seizures
• D. Position the client on their side during a seizure

Correct answer: D

Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.

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