Nokea
The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?
- A. Examine the entire system and tubing for air leaks.
- B. Lower the level of suction.
- C. Nothing; vigorous bubbling is expected
- D. Ask the patient to cough forcefully.
Correct Answer: A
Rationale: The nurse should examine the entire system and tubing for air leaks when observing vigorous bubbling in the water-seal chamber of a chest-drainage system. Vigorous bubbling indicates that there is air escaping from the system, which can lead to suboptimal drainage and potential complications. By identifying and correcting any air leaks, the nurse can ensure the chest-drainage system functions effectively, allowing for proper drainage and the prevention of complications such as pneumothorax. Lowering the level of suction or asking the patient to cough forcefully would not address the underlying issue of air leaks and may not resolve the problem effectively.
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The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made?
- A. "I will report any fever to my primary health care provider."
- B. "I am glad I only have to take the immunosuppressant medication for two weeks."
- C. "I will observe my incision for any redness or swelling."
- D. "I won't miss doing kidney dialysis every week."
Correct Answer: B
Rationale: The statement "I am glad I only have to take the immunosuppressant medication for two weeks" indicates a misunderstanding about the long-term nature of immunosuppressant therapy following a renal transplant. In reality, individuals who undergo a renal transplant need to take immunosuppressant medications for the rest of their lives to prevent rejection of the donor kidney. Failure to adhere to this medication regimen can result in rejection of the transplanted kidney. Therefore, this statement indicates a need for further teaching to ensure the adolescent understands the importance of lifelong immunosuppressant therapy.
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: In the case of Mr. Dela Isla, who suffered a CVA, one of the most important discharge teachings would be drug compliance. Following a stroke, patients are often prescribed medications to help manage their condition and reduce the risk of further complications. It is crucial for Mr. Dela Isla to understand the importance of taking his medications as prescribed by his healthcare provider. Non-compliance with medication regimens can have serious consequences and may increase the likelihood of recurrent strokes or other health issues. Therefore, ensuring that Mr. Dela Isla understands the purpose of his medications, how to take them correctly, and the potential side effects is essential for his recovery and ongoing health management. While emergency numbers, relaxation techniques, and dietary prescriptions are important aspects of care, ensuring drug compliance is critical for the immediate and long-term well-being of a patient who has experienced a stroke.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. cruises
Correct Answer: D
Rationale: Cruising typically occurs later, around 9-10 months.
Many factors in nasopharyngeal carcinoma patients may affect the prognosis. Which of the following carries the worst outcome?
- A. elevated lactate dehydrogenase (LDH) level
- B. advanced disease
- C. extensive cervical lymph node involvement
- D. evidence of Epstein-Barr virus (EBV) DNA
Correct Answer: A
Rationale: Elevated LDH levels are strongly associated with aggressive disease and poor prognosis.
When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. This should be interpreted as a(n):
- A. normal finding.
- B. hydrocele.
- C. absence of testes.
- D. inguinal hernia.
Correct Answer: B
Rationale: A hydrocele presents as a fluid-filled sac surrounding the testes within the scrotum. In newborns, it is a common finding due to the open connection between the peritoneal cavity and the scrotum that may allow fluid to accumulate. This can result in a large, edematous, and pendulous scrotum. Hydroceles are usually benign and tend to resolve on their own within the first year of life. In contrast, the absence of testes (cryptorchidism) would be identified as the inability to palpate the testes in the scrotum or inguinal canal. An inguinal hernia would present as a bulge in the inguinal area caused by a loop of intestine protruding through a weak spot in the abdominal wall.