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A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.
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A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
- A. The client moves the cane 2 feet ahea
- B. The client advances the weaker leg forward to the cane.
- C. The client takes a step with their right foot first.
- D. The client holds the cane with their left han
Correct Answer: B
Rationale: The correct answer is B. Advancing the weaker leg forward to the cane provides stability and support, helping distribute weight evenly and preventing falls. This step is crucial in using a quad cane effectively. Moving the cane too far ahead (A) could cause imbalance. Taking a step with the stronger leg first (C) would not provide the needed support for the weaker side. Holding the cane with the same side as the weakness (D) may not provide the necessary support. It is essential to prioritize stability and weight distribution, making option B the correct choice.
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema?
- A. Excessive somnolence
- B. Epistaxis
- C. Pink
- D. frothy sputum
- E. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Pink frothy sputum. This finding indicates pulmonary edema, which is characterized by fluid accumulation in the lungs. The pink color indicates the presence of blood in the sputum, a common sign of pulmonary edema. Excessive somnolence (A) is more indicative of respiratory depression or hypoxia, while epistaxis (B) is associated with hypertension or nasal trauma. Tachypnea (E) can be a sign of respiratory distress but does not specifically indicate pulmonary edema.
A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
- A. Adventitious breath sounds
- B. Respiratory rate of 24/min
- C. Weight loss of 1.8 kg (4 lb) in the past 24 hr
- D. Elevation in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Weight loss of 1.8 kg (4 lb) in the past 24 hr. Furosemide is a diuretic that helps to reduce fluid retention, so weight loss indicates the medication is effectively reducing pulmonary edema. Adventitious breath sounds indicate respiratory issues, not medication effectiveness. A respiratory rate of 24/min could be within normal range and not necessarily indicative of medication effectiveness. Elevation in blood pressure could indicate a potential adverse effect of furosemide, not effectiveness. Weight loss is the most direct indicator of reduced fluid volume due to diuresis.
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
- A. Decreased anxiety
- B. Emesis of 250 mL
- C. Increased respiratory rate to 26/min
- D. Decreased urinary output
Correct Answer: A
Rationale: The correct answer is A: Decreased anxiety. Morphine is often used to relieve pain and anxiety in patients with acute heart failure. The nurse should expect a reduction in anxiety as a positive response to the medication. Emesis (choice B) is not a typical indication of morphine effectiveness. Increased respiratory rate (choice C) may indicate respiratory depression, a potential adverse effect of morphine. Decreased urinary output (choice D) could suggest decreased cardiac output, which is not necessarily a sign of morphine effectiveness in this case.
A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control?
- A. Postprandial blood glucose level
- B. Glycosylated hemoglobin level
- C. Fasting blood glucose level
- D. Oral glucose tolerance test results
Correct Answer: B
Rationale: The correct answer is B: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. Monitoring glycosylated hemoglobin levels helps assess the effectiveness of the client's diabetes management plan over time.
A: Postprandial blood glucose level reflects short-term control after a meal.
C: Fasting blood glucose level reflects current blood glucose levels but not long-term control.
D: Oral glucose tolerance test results evaluate how the body handles glucose, not long-term control.
In summary, monitoring glycosylated hemoglobin levels is crucial for assessing long-term glycemic control in clients with diabetes.