Nokea
While caring for a client with bilateral chest tubes, the bubbling in the water-seal chamber of the right chest tube stops. What action is most important for the nurse to take?
- A. Check the chest tube connections to the water-seal container
- B. Replace the water-seal collection container
- C. Increase the amount of wall suction connected to the right chest tube
- D. Milk the tubing connected to the right chest tube
Correct Answer: A
Rationale: The most important action for the nurse to take when the bubbling in the water-seal chamber of the right chest tube stops is to check the chest tube connections to the water-seal container. This is crucial to ensure there are no disconnections or leaks affecting the bubbling. Replacing the water-seal collection container (choice B) is not necessary unless there is a malfunction; increasing suction (choice C) without assessing the connections can be harmful, and 'milking' the tubing (choice D) is an inappropriate action that can cause damage to the system.
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A client who had a cerebrovascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
- A. Risk for impaired tissue integrity related to impaired physical mobility
- B. Impaired skin integrity related to altered circulation and pressure
- C. Ineffective tissue perfusion related to inability to move self in bed
- D. Impaired physical mobility related to the left-side paralysis
Correct Answer: B
Rationale: The correct answer is B: 'Impaired skin integrity related to altered circulation and pressure.' This nursing diagnosis is the most appropriate as it directly addresses the Stage II pressure ulcer on the left hip, which is caused by altered circulation and pressure due to the client's left-side paralysis. Choice A is incorrect because it focuses on the risk for impaired tissue integrity rather than the current issue of impaired skin integrity. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this scenario. Choice D is incorrect as it only addresses the left-side paralysis and not the pressure ulcer or altered circulation.
When taking a health history of a client admitted with acute pancreatitis, which client complaint should be expected?
- A. A low-grade fever and left lower abdominal pain
- B. Severe headache and sweating all the time
- C. Severe mid-epigastric pain after ingesting a heavy meal
- D. Dull, continuous, right lower quadrant pain and nausea
Correct Answer: C
Rationale: The correct answer is C: 'Severe mid-epigastric pain after ingesting a heavy meal.' This symptom is characteristic of acute pancreatitis due to inflammation of the pancreas, which often presents with severe pain in the mid-epigastric region that may worsen after eating. Choices A, B, and D describe symptoms that are not typically associated with acute pancreatitis. A low-grade fever and left lower abdominal pain (Choice A) may be more indicative of other conditions like diverticulitis. Severe headache and sweating (Choice B) are commonly seen in conditions like migraines or infections. Dull, continuous, right lower quadrant pain and nausea (Choice D) could be suggestive of appendicitis rather than acute pancreatitis.
An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today?
- A. Assist the client in identifying goals for the day
- B. Encourage the client to participate in a team sport for one hour
- C. Schedule the client for a group session that focuses on self-esteem
- D. Help the client develop a list of daily affirmations
Correct Answer: A
Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.
The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance?
- A. Wearing gloves when providing care to the client
- B. Encouraging the client to join a support group
- C. Shaking hands with the client during an introduction
- D. Allowing the client to express their feelings openly
Correct Answer: B
Rationale: Encouraging the client to join a support group is the best option to address the client's psychosocial need for acceptance. Support groups provide a sense of belonging, understanding, and acceptance from peers who share similar experiences. This helps the client feel accepted despite their condition. Wearing gloves when providing care, shaking hands during an introduction, and allowing the client to express feelings openly are important but do not directly address the client's need for acceptance.
When should the nurse conduct an Allen's test?
- A. When obtaining pulmonary artery pressures
- B. To assess for the presence of a deep vein thrombus in the leg
- C. Just before arterial blood gases are drawn peripherally
- D. Prior to attempting a cardiac output calculation
Correct Answer: C
Rationale: The correct time to conduct an Allen's test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen's test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen's test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen's test is not done specifically before attempting a cardiac output calculation.