Nokea
The nurse notes that a client who has undergone a thoracotomy has an increase in a large amount of dark red blood in the chest tube collection chamber. What action should the nurse take?
- A. Document the findings for this procedure as expected
- B. Notify the healthcare provider immediately
- C. Check the tube for kinks or dependent loops
- D. Increase the suction to the chest drainage system
Correct Answer: B
Rationale: An increase in a large amount of dark red blood in the chest tube collection chamber may indicate active bleeding. The nurse should notify the healthcare provider immediately to address the situation promptly and prevent further complications. Documenting the findings without taking immediate action could delay necessary interventions. Checking the tube for kinks or dependent loops is a good practice but not the priority when dealing with a potentially life-threatening situation like active bleeding. Increasing the suction without healthcare provider's orders can lead to complications and is not appropriate in this scenario.
You may also like to solve these questions
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which clinical finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Heart rate of 110 beats per minute
- C. Blood pressure of 140/90 mmHg
- D. Respiratory rate of 24 breaths per minute
Correct Answer: A
Rationale: A fever of 100.4°F is a clinical finding that requires immediate intervention in a client with ESRD scheduled for hemodialysis. Fever may indicate an underlying infection, which can be severe in individuals with compromised renal function. Prompt assessment and treatment are essential to prevent worsening of the infection and potential complications. Heart rate, blood pressure, and respiratory rate are also important parameters to monitor in clients with ESRD, but in this scenario, the fever takes precedence due to its potential to indicate a critical condition that requires urgent attention.
An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?
- A. Identify pills in the bag
- B. Review the client's medication schedule
- C. Assess the client's symptoms
- D. Educate the client about proper medication usage
Correct Answer: A
Rationale: The correct answer is to identify pills in the bag first. This is essential to ensure the client is taking the correct medications and to prevent any potential medication errors. Reviewing the client's medication schedule (choice B) can come after identifying the pills to cross-reference the medications. Assessing the client's symptoms (choice C) is important but should follow identifying the medications. Educating the client about proper medication usage (choice D) is crucial but should be done after confirming the medications in the bag.
The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?
- A. Fetal heart rate of 200 beats/minute.
- B. Mild ankle edema.
- C. Complaints of back pain.
- D. Decreased fetal movements.
Correct Answer: A
Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.
A client who has just returned from surgery is shivering uncontrollably. What is the best action for the nurse to take?
- A. Offer the client a warm blanket
- B. Apply warm blankets and monitor the client's temperature
- C. Place a warm blanket in the client's bed before transferring the client from the stretcher
- D. Administer a prescribed muscle relaxant
Correct Answer: B
Rationale: Applying warm blankets and monitoring the client's temperature is the best action to manage postoperative shivering. Shivering after surgery can be a common response due to factors like exposure to cold, pain, or anesthesia effects. Providing warmth through blankets can help regulate the client's body temperature and alleviate shivering. Monitoring the client's temperature is essential to ensure it returns to a normal range. Option A is not as comprehensive as option B, which includes both providing warmth and monitoring the client. Option C is incorrect as it focuses on preparing the bed rather than addressing the client's immediate need for warmth. Option D is not appropriate without further assessment or prescription for a muscle relaxant to address shivering.
The nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?
- A. Jugular venous distention
- B. Peripheral edema
- C. Crackles in the lungs
- D. Elevated liver enzymes
Correct Answer: C
Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.