Question

The nurse would check for leaks in the chest tube and water seal system when:

Answer 1

Correct Answers:

there is continuous bubbling in the water-seal chamber.

Rationale :

🔍Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube drainage system, which must be evaluated and corrected promptly.

🩺Intermittent bubbling may be normal with pneumothorax during exhalation, but continuous bubbling suggests that air is entering where it shouldn’t.

📉Fluid fluctuation with respiration is a normal finding and indicates that the system is patent and functioning.

🚫Constant bubbling in the suction-control chamber is expected and not a sign of a problem.

📌Core Message

Continuous bubbling in the water-seal chamber suggests an air leak and requires prompt investigation.

Answer 2

Correct Answers:

Blood pressure of 90/50

Rationale :

💊Nitroglycerin causes vasodilation, which can lead to hypotension, especially in clients already experiencing low blood pressure.

⚠️A BP of 90/50 mmHg is concerning because it may cause decreased coronary perfusion, worsening myocardial ischemia.

📉This side effect must be reported before titrating or continuing the infusion to avoid shock or cardiac arrest.

🧪A slightly abnormal potassium or ECG changes are monitored but are not as immediately life-threatening as hypotension in this context.

📌Core Message

Report hypotension before continuing nitroglycerin infusion in MI management.

Answer 3

Correct Answers:

Change position slowly to prevent orthostatic hypotension

Rationale :

💊Carbidopa/levodopa is a dopamine precursor that often causes orthostatic hypotension, especially during treatment initiation.

🪑Teaching clients to rise slowly prevents falls and injuries due to sudden drops in blood pressure.

🚫The drug should never be stopped abruptly or doubled—this could result in serious complications like neuroleptic malignant syndrome.

📛Increased urination is not a key side effect of this drug class.

📌Core Message

Orthostatic hypotension is a common side effect of carbidopa/levodopa, requiring position changes slowly.

Answer 4

Correct Answers:

relief of chest pain

Rationale :

💓The primary goal of IV nitroglycerin in acute MI is relief of ischemic chest pain by vasodilation of coronary arteries.

💁‍♂️This reduces myocardial oxygen demand and improves coronary blood flow.

📉Although BP may drop and HR may change, those are secondary effects, not the main indicator of effectiveness.

💡Monitoring pain relief is the best measure to assess if myocardial perfusion has improved.

📌Core Message

Pain relief is the key indicator of nitroglycerin effectiveness during acute MI.

Answer 5

Correct Answers:

ventricular dysrhythmias

Rationale :

⚡Anterior wall MIs are strongly associated with ventricular dysrhythmias due to injury to the left anterior descending artery, which supplies the ventricular conduction system.

📟These dysrhythmias can be fatal and are a priority for continuous monitoring in the first few hours.

🚫Murmurs or friction rubs develop later and are less urgent.

🧪Renal changes are not a direct early complication of MI.

📌Core Message

Ventricular dysrhythmias are a major early complication of anterior wall myocardial infarction.

Answer 6

Correct Answers:

uncompensated metabolic acidosis.

Rationale :

🧪ABG: pH 7.32 (low), PaCO₂ 33 mmHg (low-normal), HCO₃ 16 mEq/L (low) → indicates metabolic acidosis.

📉Since the PaCO₂ hasn't decreased enough to normalize pH, it's uncompensated.

💊Compensation would require a significant drop in PaCO₂ to bring pH back toward the normal range.

📊ABG values clearly show a primary metabolic cause without respiratory compensation yet.

📌Core Message

Low pH and HCO₃ with normal PaCO₂ confirms uncompensated metabolic acidosis.

Answer 7

Correct Answers:

56

Rationale :

🧮Use formula: (Volume × Drop Factor) ÷ Time = (500 × 10) ÷ 90 = 55.55, round to 56 gtt/min.

📏This formula ensures accurate flow rate using gravity infusion sets.

⚠️Incorrect calculation could lead to under- or over-infusion, affecting patient outcomes.

🧠Always round to the nearest whole number when dealing with drops per minute.

📌Core Message

Use the gtt/min formula to accurately calculate gravity IV infusion rate.

Answer 8

Correct Answers:

take pyridostigmine 30-60 minutes before meals to improve muscle function."

Rationale :

💊Pyridostigmine enhances neuromuscular transmission by inhibiting acetylcholinesterase, improving muscle strength in myasthenia gravis (MG).

🍽️Taking it 30–60 minutes before meals allows optimal swallowing and chewing, reducing aspiration risk.

🚫This is not a PRN medication—it should be taken consistently.

📛Sustained-release tablets should not be crushed, and fatigue is a sign the dose might be inadequate—not a reason to skip.

📌Core Message

Take pyridostigmine before meals to maximize muscle strength for safe eating in MG.

Answer 9

Correct Answers:

Tachypnea

Rationale :

💁‍♂️ARDS leads to pulmonary edema and impaired gas exchange, resulting in tachypnea as a compensatory response.

📸A chest X-ray showing bilateral infiltrates confirms fluid buildup in the alveoli.

💨Clients often breathe rapidly to compensate for hypoxemia.

🚫Wheezes are not typical; BP may vary, and bradycardia is not expected unless hypoxia is severe.

📌Core Message

Tachypnea is a primary response in ARDS due to severe oxygenation impairment.

Answer 10

Correct Answers:

Muscle rigidity and bradykinesia

Rationale :

🧠Parkinson’s disease is a neurodegenerative disorder marked by loss of dopamine, resulting in rigidity, tremors, and bradykinesia.

🚶Clients have difficulty initiating movement, and stiffness leads to the classic shuffling gait and reduced facial expression.

📛Ptosis is more neurological (e.g., MG), and bruising/petechiae are hematologic signs.

💩GI symptoms like diarrhea are not typical features of Parkinson’s.

📌Core Message

Parkinson’s disease presents with bradykinesia and muscle rigidity from dopamine deficiency.

ABG Value	Normal Range
pH	7.35 – 7.45
PaCO₂	35 – 45 mmHg
HCO₃⁻	22 – 25 mEq/L
Base excess	–2 to +2
PaO₂	80 – 95 mmHg
SaO₂	>95%

1 :
The nurse would check for leaks in the chest tube and water seal system when:

2 :
The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

3 :
A nurse is providing teaching to a client newly diagnosed with Parkinson's disease who is prescribed carbidopa/levodopa. What should be included in client teaching?

4 :
The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

5 :
The nurse monitors the client in the immediate hours following an anterior-lateral wall myocardial infarction for the development of:

6 :
The nurse is caring for a client with the following arterial blood gas (ABG) results: pH 7.32, PaC02 33 mmHg, Pa02 88 mmHg, HC03 16 mEg/L.

Answer Options

7 :
A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt./mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

8 :
The nurse is providing education for a client diagnosed with myasthenia gravis (MG) taking pyridostigmine. The nurse understands teaching has been effective when the client states, "l will

9 :
The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?

10 :
The nurse assessing the client diagnosed with Parkinson's disease (PD) would expect which of the following assessment findings?

1 : The nurse would check for leaks in the chest tube and water seal system when:

2 : The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

3 : A nurse is providing teaching to a client newly diagnosed with Parkinson's disease who is prescribed carbidopa/levodopa. What should be included in client teaching?

4 : The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

5 : The nurse monitors the client in the immediate hours following an anterior-lateral wall myocardial infarction for the development of:

6 : The nurse is caring for a client with the following arterial blood gas (ABG) results: pH 7.32, PaC02 33 mmHg, Pa02 88 mmHg, HC03 16 mEg/L.

Answer Options

7 : A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt./mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

8 : The nurse is providing education for a client diagnosed with myasthenia gravis (MG) taking pyridostigmine. The nurse understands teaching has been effective when the client states, "l will

9 : The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?

10 : The nurse assessing the client diagnosed with Parkinson's disease (PD) would expect which of the following assessment findings?

1 :
The nurse would check for leaks in the chest tube and water seal system when:

2 :
The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

3 :
A nurse is providing teaching to a client newly diagnosed with Parkinson's disease who is prescribed carbidopa/levodopa. What should be included in client teaching?

4 :
The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

5 :
The nurse monitors the client in the immediate hours following an anterior-lateral wall myocardial infarction for the development of:

6 :
The nurse is caring for a client with the following arterial blood gas (ABG) results: pH 7.32, PaC02 33 mmHg, Pa02 88 mmHg, HC03 16 mEg/L.

7 :
A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt./mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

8 :
The nurse is providing education for a client diagnosed with myasthenia gravis (MG) taking pyridostigmine. The nurse understands teaching has been effective when the client states, "l will

9 :
The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?

10 :
The nurse assessing the client diagnosed with Parkinson's disease (PD) would expect which of the following assessment findings?