Nokea
A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?
- A. Clamp the tube when the client is ambulating.
- B. Keep the collection device below the level of the client's chest.
- C. Carefully coil the tubes to prevent kinking.
- D. Position the client flat to avoid leaks in the tubing.
Correct Answer: B
Rationale: The correct answer is B: Keep the collection device below the level of the client's chest. This is important to ensure proper drainage and prevent backflow or air from entering the pleural space. Placing the collection device below the chest allows gravity to assist in drainage. Clamping the tube while ambulating (choice A) can lead to increased pressure in the chest, risking complications. Coiling the tubes (choice C) may cause kinks, obstructing drainage. Positioning the client flat (choice D) can lead to leaks in the tubing due to elevated pressure.
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What nursing measure would be most helpful in soliciting Mr. Ross’s cooperation with arm and shoulder exercises?
- A. Inform Mr. Ross that these exercises must be done before each meal and at bedtime
- B. Give Mr. Ross a booklet which diagrams the exercises
- C. Teach Mrs. Ross how to do these exercises
- D. Ask Mr. Ross which times are most convenient for him to exercise
Correct Answer: D
Rationale: Tailoring exercise schedules to patient preferences enhances adherence.
What might have been the precipitating cause of Wendy’s asthmatic attack?
- A. Breaking up with her boyfriend
- B. Personal history of allergies
- C. Restless sleeping pattern
- D. Smoking five cigarettes daily
Correct Answer: B
Rationale: Allergies are common triggers for asthma exacerbations.
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 Stripping the chest tube (B) is outdated and can cause damage.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.
Where was the mistake made in the nursing process with this patient?
- A. Planning
- B. Diagnosis
- C. Evaluation
- D. Assessment
Correct Answer: B
Rationale: The initial diagnosis of ineffective self-health management overlooked the financial barrier, which is a root cause rather than lack of knowledge.
A healthcare professional is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the healthcare professional anticipate administering?
- A. Furosemide
- B. Dexamethasone
- C. Heparin
- D. Atropine
Correct Answer: C
Rationale: The correct answer is C: Heparin. Heparin is a common anticoagulant used to prevent further clotting in patients with pulmonary embolism. It works by inhibiting blood clot formation. Furosemide (A) is a diuretic used for conditions like heart failure and edema, not for pulmonary embolism. Dexamethasone (B) is a corticosteroid used for inflammation and immune suppression, not for pulmonary embolism. Atropine (D) is used to treat bradycardia and not indicated for pulmonary embolism. Administering heparin is crucial to prevent worsening of the pulmonary embolism and potential life-threatening complications.