Nokea
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
- A. S3 heart sound.
- B. Thready pulse.
- C. Flattened neck veins.
- D. Hypoventilation.
Correct Answer: A
Rationale: An S3 heart sound indicates volume overload.
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Which BMI is typically associated with anorexia nervosa?
- A. Increase protein intake
- B. Reduce carbohydrate consumption
- C. Drink more water
- D. Take vitamin supplements
Correct Answer: C
Rationale: The correct answer is C because it is the most appropriate response based on physiological and medical principles.
Which tubes drain gastric contents (select all that apply)?
- A. T-tube
- B. Hemovac
- C. Nasogastric tube
- D. Indwelling catheter
Correct Answer: D
Rationale: Nasogastric and gastrointestinal tubes drain gastric contents effectively.
The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?
- A. Serum K+ of 3.8 mEq/L
- B. Hemoglobin of 15 g/dL
- C. Blood glucose of 100 mg/dL
- D. White blood cell (WBC) count of 18,500/µL
Correct Answer: D
Rationale: An elevated WBC count indicates potential infection, requiring immediate attention.
After administering injections of penicillin, the nurse should ask the client to wait at least __ minutes before allowing the client to leave the healthcare facility.
- A. 12
- B. 15
- C. 5
- D. 30
Correct Answer: B
Rationale: The rationale is that waiting 15 minutes allows time to observe for any adverse reactions to the medication.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks.
1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system.
2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue.
3. This helps maintain the integrity of the closed chest drainage system and prevent complications.
Other choices are incorrect:
B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system.
C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician.
D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.