Nokea
A client has a chest tube in place with a three-chamber chest drainage system. The nurse notes continuous bubbling in the water seal chamber. This indicates which of the following?
- A. Pneumothorax.
- B. Suction is adequate.
- C. System air leak.
- D. The tube is positioned incorrectly.
Correct Answer: C
Rationale: Continuous bubbling in the water seal chamber indicates a system air leak (C), such as a loose connection or hole in the tubing. A pneumothorax (A) may cause intermittent bubbling, adequate suction (B) is indicated by bubbling in the suction chamber, and incorrect tube positioning (D) would not typically cause continuous bubbling.
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The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should:
- A. Place tape completely around the extremity, with tape ends out of the client's vision
- B. Tell him that if he pulls out the IV, it will have to be restarted
- C. Slap the client's hand when he reaches toward the IV site
- D. Apply clove hitch restraints to the client's hands
Correct Answer: A
Rationale: Securing the IV with tape out of the client's vision minimizes tampering while avoiding restraints or inappropriate actions.
A nurse must teach a client how to do wound care and dressing changes prior to discharge. Which of the following are barriers to learning? Select all that apply.
- A. The client is 55 years old.
- B. The client is fearful.
- C. The client is illiterate.
- D. The client is weak and frail.
- E. The client has many questions about the procedures.
- F. The client is hard of hearing.
Correct Answer: B,C,F
Rationale: Barriers to learning include fear (B), which can hinder concentration; illiteracy (C), which affects understanding written instructions; and hearing impairment (F), which impedes verbal communication. Age 55 (A), weakness (D), and asking questions (E) are not barriers.
A Turkish-speaking client is scheduled for a colonoscopy, and the nurse must provide printed directions to the client, but directions are not available in Turkish. Which of the following is most appropriate?
- A. The nurse contacts a medical translator to translate.
- B. The client's 10-year-old daughter translates the directions.
- C. The nurse draws pictures and pantomimes directions.
- D. Client's daughter is advised to tell her parent to seek a translator.
Correct Answer: A
Rationale: Contacting a medical translator (A) ensures accurate communication for critical medical instructions. Using a child (B) is unreliable, pictures/pantomime (C) may be unclear, and advising the daughter to find a translator (D) shifts responsibility inappropriately.
A client is admitted for an CAT scan. The nurse should question the client regarding:
- A. Pregnancy
- B. A titanium hip replacement
- C. Allergies to antibiotics
- D. Inability to move his feet
Correct Answer: A
Rationale: Pregnancy is a contraindication for a CAT scan due to radiation risks to the fetus.
A client is taking nebulizer treatments for asthma, and the nurse is instructing the client in the correct method for measuring peak expiratory flow rates (PEFR) after treatment. The nurse prepares the meter with the indicator at the base of the scale. Place the following steps (Roman numerals) in the correct order from first to last.
- A. Client sits upright or stands.
- B. Client places the meter in the mouth and seals lips.
- C. Client expels air through the meter as forcefully as possible.
- D. Client takes a deep breath.
Correct Answer: A,D,B,C
Rationale: PEFR sequence: Sit/stand (I), take deep breath (IV), place meter in mouth (II), expel air forcefully (III).