Nokea
A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
- A. Increase the wall suction.
- B. Strip the chest tube.
- C. Clamp the chest tube.
- D. Reposition the client.
Correct Answer: D
Rationale: The correct answer is D: Reposition the client. This action should be taken because chest burning could indicate that the chest tube is irritating the pleura. Repositioning the client may help alleviate the pressure on the pleura, reducing discomfort. Increasing wall suction (A) could worsen the irritation. Stripping the chest tube (B) is outdated and can cause damage. Clamping the chest tube (C) can lead to tension pneumothorax.
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Mandy is a 17-year-old adolescent girl. On physical examination you note partial erosion of her tooth enamel and callus formation on the posterior aspect of the knuckles of her hand. This is indicative of
- A. A connective tissue disorder; she should be referred to dermatology.
- B. Self-induced vomiting; she likely has bulimia nervosa.
- C. Self-mutilation; this correlates with anxiety.
- D. A genetic disorder; her siblings should also be tested.
Correct Answer: B
Rationale: Erosion of tooth enamel and calluses on knuckles are common signs of self-induced vomiting seen in bulimia nervosa.
Following segmental resection for bronchiectasis, what is most important for Mr. Jones?
- A. Cough and deep breathe every 1-2 hours
- B. Limit fluid intake
- C. Lie flat in bed
- D. Receive analgesia every 6 hours
Correct Answer: A
Rationale: Regular coughing and deep breathing prevent atelectasis and pneumonia.
Describe assessment data for the suicidal client.
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct Answer: C
Rationale: Step 1: Checking the oximeter is essential to assess the client's oxygen saturation levels immediately post-procedure.
Step 2: Hypoxia can lead to serious complications, impacting the client's neurological status.
Step 3: The nurse must prioritize oxygenation status to prevent further brain injury or hypoxemia.
Step 4: Observing for CSF leaks, assessing temperature, and monitoring ICP are important but not as immediate as ensuring adequate oxygen supply.
Summary: Option C is correct as it addresses the most critical and immediate concern post-procedure, ensuring optimal oxygenation for the client's neurological recovery. Options A, B, and D are important but secondary to maintaining oxygen levels.
Which value shows the normal range of plasma pH?
- A. 7.35 to 7.45
- B. 6.35 to 6.45
- C. 7 to 8
- D. 8.35 to 8.45
Correct Answer: A
Rationale: The normal range of plasma pH is 7.35 to 7.45, which indicates a slightly alkaline environment essential for proper cellular function.