Nokea
A client has a chest tube attached to a waterseal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine:
- A. The lung has fully expanded.
- B. The lung has collapsed.
- C. The chest tube is in the pleural space.
- D. The mediastinal space has decreased.
Correct Answer: A
Rationale: Lack of fluctuation in the water-seal column suggests the lung has fully expanded, resolving the pneumothorax. Collapsed lung, tube placement, or mediastinal changes would show other signs.
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A client with a hip fracture is receiving heparin to prevent thromboembolism. Which laboratory value should the nurse monitor?
- A. Prothrombin time (PT).
- B. Activated partial thromboplastin time (aPTT).
- C. International Normalized Ratio (INR).
- D. Platelet count.
Correct Answer: B
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation.
A nurse is preparing to administer furosemide intravenously to a client. Which action should the nurse perform before administering this medication?
- A. Insert an indwelling urinary catheter.
- B. Review the client's most recent pulse
- C. Establish continuous pulse oximeter monitoring
- D. Assess the client's serum electrolytes
Correct Answer: D
Rationale: Furosemide can cause electrolyte imbalances, so assessing serum electrolytes is critical before administration.
Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)?
- A. Fluid retention.
- B. Pain.
- C. Peripheral edema.
- D. Hunger.
Correct Answer: B
Rationale: Pain, particularly abdominal, is a common symptom in addisonian crisis due to electrolyte imbalances and hypotension.
The nurse is caring for a client who has been prescribed infusions of amphotericin b. Which laboratory data is necessary for the nurse to monitor during treatment?
- A. Triglycerides
- B. Hemoglobin A1C
- C. Potassium
- D. High-density lipoprotein (HDL)
Correct Answer: C
Rationale: Amphotericin B can cause electrolyte imbalances, particularly hypokalemia, so monitoring potassium levels (Choice C) is essential. Choices A (triglycerides), B (hemoglobin A1C), and D (HDL) are not directly affected by amphotericin B and are not routinely monitored during treatment.
The nurse is planning a staff development conference about medication safety. Which of the following medications should have a second medication check prior to administration? Select all that apply.
- A. heparin infusion
- B. regular insulin
- C. 0.9% sodium chloride (normal saline) flush
- D. patient-controlled analgesia (PCA)
- E. oxytocin infusion
- F. total parenteral nutrition
Correct Answer: A,B,D,E,F
Rationale: High-risk medications like heparin, insulin, PCA, oxytocin, and TPN require a second check to prevent errors.