Nokea
A 46 year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
- A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
- B. Allow the patient to begin limited ambulation with assistance.
- C. Recommend a physical therapy consultation for ambulation.
- D. Tell the patient to remain with leg straight for another 6 hours and check the chart for activity orders.
Correct Answer: A
Rationale: The patient should keep the leg straight for at least 4 hours.
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A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level.
Which medication might the physician order if the client expresses discomfort with being in the enclosed space of a CT scanner?
- A. Valium (diazepam)
- B. Clozaril (clozapine)
- C. Catapress (clonidine)
- D. Lasix (furosemide)
Correct Answer: A
Rationale: Valium, a sedative, is appropriate to reduce anxiety and discomfort in a confined CT scanner, unlike the other medications, which have different indications.
A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?
- A. Notify the physician.
- B. Clamp the chest tube.
- C. Replace the system.
- D. Document the finding.
Correct Answer: D
Rationale: Gentle bubbling is a normal finding for the client who has a pleural drainage system to suction, so it simply needs to be documented. If the bubbling becomes vigorous, it could indicate a leak, which the nurse needs to investigate. The remaining choices are not necessary.
The most common cause of injury from a house fire is:
- A. explosion
- B. falls from second-story windows
- C. thermal damage to skin and body surfaces
- D. inhalation injury
Correct Answer: D
Rationale: Inhalation injury, due to smoke and toxic gases, is the most common cause of injury in house fires, often leading to respiratory distress or death before burns become critical.
A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct Answer: A
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak.