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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Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct Answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
The nurse is teaching a client about dietary modifications to control hypertension. Which statement by the client indicates a need for further teaching?
- A. I can have a cup of fresh fruit as a snack.
- B. Baked ham is a good dinner choice for me.
- C. I need to check the label for sodium in ketchup.
- D. I need to cut out frozen pizza as a fast meal option.
Correct Answer: B
Rationale: Baked ham is high in sodium, which is unsuitable for hypertension. Other choices align with low-sodium dietary recommendations.
The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions should the nurse teach the client to follow?
- A. Keep glucose tablets.
- B. Monitor the urine for acetone.
- C. Report any feelings of drowsiness.
- D. Omit the evening dose of NPH insulin if the client has been exercising.
Correct Answer: A
Rationale: Glucose tablets are taken if a hypoglycemic reaction occurs. Glucagon is also a medication that may be prescribed to be administered subcutaneously or intramuscularly if the client loses consciousness and is unable to take glucose by mouth. Glucagon releases glycogen stores and raises the blood glucose levels of hypoglycemic clients. Family members can be taught to administer this medication and possibly to prevent an emergency department visit. Acetone in the urine may indicate hyperglycemia. Although signs/symptoms of hypoglycemia need to be taught to the client, drowsiness is not the initial and key sign of this complication. The nurse should not instruct a client to omit insulin.
Which action by the client should lead the nurse to determine the need for further teaching regarding the use of the incentive spirometer?
- A. Inhales slowly
- B. Breathes through the nose
- C. Removes the mouthpiece to exhale
- D. Forms a tight seal around the mouthpiece with the lips
Correct Answer: B
Rationale: Incentive spirometry is ineffective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 5, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.
The nurse is teaching a smoking cessation program. He will state that which of the following benefits of quitting appear within one year?
- A. risk of coronary heart disease is the same as that of a nonsmoker
- B. carbon monoxide level in blood drops to normal
- C. risk of dying from lung cancer is about half that of a smoker's
- D. risk of having a stroke is reduced to that of a nonsmoker's
Correct Answer: B
Rationale: Within 24 hours of quitting smoking, carbon monoxide levels drop to normal. Other benefits (A, C, D) take longer (5-15 years for heart disease, 10 years for lung cancer, 5-10 years for stroke risk). Thus, B is the correct benefit within one year.