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What is the nurse's responsibility when caring for a client with a chest tube?
- A. Check for air leaks in the tubing every 4 hours
- B. Clamp the chest tube for 30 minutes every 4 hours
- C. Encourage deep breathing and coughing every 2 hours
- D. Keep the client in a high Fowler's position
Correct Answer: A
Rationale: The correct answer is to check for air leaks in the tubing every 4 hours when caring for a client with a chest tube. This responsibility is crucial because it ensures proper chest tube function and helps prevent complications such as pneumothorax or hemothorax. Clamping the chest tube (Choice B) can lead to serious issues by causing a tension pneumothorax. Encouraging deep breathing and coughing (Choice C) is important for respiratory hygiene but is not directly related to chest tube care. Keeping the client in a high Fowler's position (Choice D) may be beneficial for some conditions but is not specific to chest tube management.
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A client has developed phlebitis at the IV site. What is the most appropriate next step?
- A. Apply a warm compress over the IV site
- B. Notify the provider and discontinue the IV infusion
- C. Increase the IV flow rate to clear the blockage
- D. Elevate the extremity and apply an ice pack
Correct Answer: B
Rationale: Phlebitis, inflammation of a vein, is a complication that requires prompt action. The most appropriate next step is to discontinue the IV infusion and notify the healthcare provider. Applying a warm compress, increasing the IV flow rate, or applying an ice pack are not appropriate interventions for phlebitis. Warm compresses may worsen inflammation, increasing the IV flow rate could exacerbate the condition, and ice packs are not recommended for phlebitis.
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?
- A. Request an occupational therapy consult to determine the need for assistive devices
- B. Assign assistive personnel to perform self-care tasks for the client
- C. Instruct the client to focus on gradually resuming self-care tasks
- D. Ask the client if a family member is available to assist with his care
Correct Answer: C
Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence following an acute myocardial infarction. This approach allows the client to regain confidence and control over their self-care activities without feeling overwhelmed. Requesting an occupational therapy consult (Choice A) may be beneficial but is not the immediate solution to promote independence. Assigning assistive personnel (Choice B) to perform tasks for the client does not encourage independence. Asking if a family member is available for assistance (Choice D) does not directly promote the client's independence.
A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?
- A. Change the appliance daily
- B. Clean the stoma once a day
- C. Avoid changing the appliance for a week
- D. Change the appliance twice each week
Correct Answer: D
Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.
A client has a prescription for ciprofloxacin. Which of the following instructions should the nurse include?
- A. Take the medication with an antacid if you experience gastrointestinal upset.
- B. You should limit your caffeine intake while taking this medication.
- C. This medication may cause your urine to turn dark brown.
- D. You should avoid taking this medication with dairy products.
Correct Answer: D
Rationale: The correct answer is D: 'You should avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice A is incorrect because ciprofloxacin should not be taken with antacids containing aluminum or magnesium. Choice B is incorrect as there is no specific limitation on caffeine intake associated with ciprofloxacin. Choice C is incorrect as ciprofloxacin does not typically cause urine to turn dark brown.
What is the priority nursing action for a patient with an acute asthma attack?
- A. Administer a bronchodilator
- B. Monitor oxygen saturation
- C. Position the patient in a high Fowler's position
- D. Call for assistance
Correct Answer: A
Rationale: The correct answer is to administer a bronchodilator. During an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators are the first-line treatment for asthma attacks as they help dilate the bronchioles, allowing for better airflow. Monitoring oxygen saturation is important but not the priority when the patient is in distress. Placing the patient in a high Fowler's position can help with breathing but is not the initial priority. Calling for assistance can be done after initiating the appropriate treatment.