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A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While repositioning the client, the nurse notices dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Prepare for blood transfusion
- D. Continue to monitor the rate of drainage
Correct Answer: D
Rationale: It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
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A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?
- A. light, pink urine
- B. occasional suprapubic cramping
- C. minimal drainage into the urinary collection bag
- D. reports of the feeling of pulling on the urinary catheter
Correct Answer: C
Rationale: Options A, B, and D are expected complaints after this procedure. Option C needs to be reported immediately since minimal urinary drainage puts the client at risk for bladder rupture.
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent episodes of alertness
Correct Answer: D
Rationale: A preschooler with intermittent episodes of alertness. A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump.
Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?
- A. obtain a complete blood count
- B. obtain a health and dietary history
- C. refer to a provider for a physical examination
- D. measure height and weight
Correct Answer: B
Rationale: obtain a health and dietary history. Initially, the nurse should obtain information about the chronicity of and details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment plan.
The nurse is preparing to care for the client diagnosed with tuberculosis who has been coughing up blood. Which illustration best shows the PPE that the nurse should plan to wear?
- A. ppe_1.PNG
- B. ppe_2.PNG
- C. ppe_3.PNG
- D. ppe_4.PNG
Correct Answer: D
Rationale: D: N95 respirator for airborne precautions and a face shield for blood exposure are appropriate. Other options lack adequate respiratory or splash protection.
The HCP prescribes metronidazole 0.5 g orally three times daily for the client with an infection. The label states that each tablet is 250 mg. How many tablets should the nurse prepare to administer for one dose?
Correct Answer: 2
Rationale: 0.5 g = 500 mg; 500 mg/ 250 mg/tablet = 2 tablets per dose.