Nokea
A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?
- A. Do nothing; this is a normal response
- B. Strip the tubing to remove any clots
- C. Place a clamp on the tube near the client's chest
- D. Remove the collection chamber and connect the tubing to a new device
Correct Answer: C
Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately.
Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak. Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action. Choice D is incorrect as it does not address the immediate need to locate and address the leak.
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A nurse is assisting a pregnant client who is having an amniocentesis.
Which of the following statements by the nurse indicates the correct
teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct Answer: D
Rationale: An amniocentesis is performed to draw amniotic luid
from the sac around the fetus during pregnancy. It may be analyzed for
certain disorders or complications associated with pregnancy.
Following the procedure, the nurse should wash the client's abdomen
and place a small bandage over the puncture site
A client with asthma is being admitted for breathing difficulties. His arterial blood gas results are pH 7.26, PCO2 49, PaO2 90, and HCO3- 21. Which of the following best describes this condition?
- A. Uncompensated respiratory acidosis
- B. Compensated respiratory alkalosis
- C. Uncompensated metabolic acidosis
- D. Compensated metabolic alkalosis
Correct Answer: A
Rationale: In this case, the client's arterial blood gas results show a pH of 7.26 and a PCO2 of 49, both of which are abnormal. A pH below the normal range of 7.35-7.45 indicates acidosis. The elevated PCO2 of 49 mmHg suggests respiratory acidosis as the primary issue. The normal range for PCO2 is 35-45 mmHg, so a value of 49 indicates the retention of excess CO2, leading to acidosis. The low HCO3- level of 21 also supports the presence of metabolic acidosis; however, the primary abnormality is respiratory, making this an uncompensated respiratory acidosis. Therefore, the correct answer is 'Uncompensated respiratory acidosis.'
Choice B, 'Compensated respiratory alkalosis,' is incorrect because the client's pH is acidic, not alkalotic. Additionally, there is no compensation occurring for the primary respiratory acidosis indicated by the elevated PCO2.
Choice C, 'Uncompensated metabolic acidosis,' is incorrect because while the HCO3- level is low, the primary issue indicated by the elevated PCO2 is respiratory acidosis.
Choice D, 'Compensated metabolic alkalosis,' is incorrect since the arterial blood gas results do not support a metabolic alkalosis. The low HCO3- level would typically be seen in metabolic acidosis, but in this case, the primary issue is respiratory acidosis.
The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?
- A. Irregular breathing patterns
- B. Minimal heartbeat, dilated pupils
- C. Relaxed muscles, regular breathing, constricted pupils
- D. Euphoria, drowsiness, dizziness
Correct Answer: D
Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.
A client has entered disseminated intravascular coagulation (DIC) after becoming extremely ill after surgery. Which of the following laboratory findings would the nurse expect to see with this client?
- A. Elevated fibrinogen level
- B. Prolonged PT
- C. Elevated platelet count
- D. Depressed d-dimer level
Correct Answer: B
Rationale: In disseminated intravascular coagulation (DIC), a client experiences widespread clotting throughout the body, leading to the depletion of clotting factors and platelets. A prolonged prothrombin time (PT) is a common finding in DIC. The PT measures the extrinsic pathway of the clotting cascade and reflects how quickly blood can clot. In DIC, the consumption of clotting factors results in a prolonged PT, indicating impaired clotting ability. Elevated fibrinogen levels (Choice A) are typically seen in the early stages of DIC due to the body's attempt to compensate for clot breakdown. Elevated platelet count (Choice C) is not a typical finding in DIC as platelets are consumed during the widespread clotting. A depressed d-dimer level (Choice D) is also not expected in DIC as d-dimer levels are elevated due to the breakdown of fibrin clots. Therefore, the correct answer is a prolonged PT.
Mrs. G is seen for follow-up after testing for chronically high blood glucose levels. Her physician diagnoses her with type 1 diabetes. Which of the following information is part of this client's education about this condition?
- A. Type 1 diabetes occurs due to increased carbohydrate intake and lack of exercise
- B. Type 1 diabetes is managed through diet and exercise
- C. Type 1 diabetes is caused by destruction of beta cells in the pancreas
- D. Type 1 diabetes leads to the body's cells rejecting insulin
Correct Answer: C
Rationale: Type 1 diabetes is an autoimmune condition where the immune system attacks and destroys the beta cells in the pancreas, leading to a lack of insulin production. Insulin is essential for regulating blood glucose levels and enabling cells to use glucose for energy. Understanding that type 1 diabetes results from the destruction of beta cells helps patients comprehend the need for insulin replacement therapy. Choices A and B are incorrect as type 1 diabetes is not primarily caused by diet or exercise habits. Choice D is incorrect because type 1 diabetes is not about the body's cells rejecting insulin but rather the lack of insulin production due to beta cell destruction.