Nokea
A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asks the nurse the purpose of the drain. What is the nurse's best response?
- A. œThe drainage tube is used to prevent infection in the peritoneal cavity.'
- B. œThe drainage tube is used to prevent bleeding into the peritoneal cavity.'
- C. œThe drainage tube is used to prevent pressure on on the bladder.'
- D. œThe drainage tube is used to prevent pressure on the gallbladder.'
Correct Answer: A
Rationale: A Jackson-Pratt drain removes fluid and blood from the surgical site, preventing infection in the peritoneal cavity by reducing fluid accumulation post-diverticulum repair.
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Thirty people are injured in a train derailment. Ineffective and the transported to the hospital first?
- A. A 20-year-old who is unresponsive and has a high injury to his spinal cord.
- B. An 80-year-old who has a compound fracture of the arm.
- C. A 10-year-old with a laceration on his leg.
- D. A 25-year-old with a sucking chest wound.
Correct Answer: D
Rationale: A sucking chest wound is a life-threatening condition that can impair breathing and requires immediate intervention, prioritizing this patient for transport over others with less urgent injuries.
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?
Correct Answer: 60 mL
Rationale: 2 oz equals 60 mL (1 oz = 30 mL), so the nurse should administer 60 mL of lactulose (A).
Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the following is the most appropriate nursing action?
- A. Insert a straight catheter.
- B. Increase I.V. fluids.
- C. Notify the surgeon.
- D. Assist the client to the bathroom.
Correct Answer: A
Rationale: A distended bladder and inability to void suggest urinary retention, common post-surgery. Inserting a straight catheter relieves the bladder and prevents complications like overdistension.
Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of:
- A. Chronic obstructive pulmonary disease.
- B. Pancreatic cancer.
- C. Renal failure.
- D. Cerebrovascular accident.
Correct Answer: C
Rationale: ACE inhibitors protect against renal failure in diabetes by reducing vascular damage and proteinuria.