Nokea
A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
- A. Continue to monitor the client.
- B. Immediately notify the healthcare provider.
- C. Reposition the client to the left side.
- D. Clamp the chest tube near the water seal.
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client. When the water seal chamber rises with client inspiration, it indicates normal functioning of the chest tube system, allowing air to exit the pleural space. Monitoring ensures proper chest tube function. Option B is incorrect because there is no indication of immediate need for healthcare provider notification. Option C is unnecessary as repositioning won't address the issue. Option D is incorrect and dangerous as clamping the chest tube can lead to tension pneumothorax.
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What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.
What symptoms would a nurse suspect in a client with acoustic neuroma?
- A. Altered facial sensation
- B. Vertigo only when standing
- C. Tinnitus in the unaffected ear
- D. Impaired facial movement when smiling
Correct Answer: A
Rationale: Acoustic neuromas often affect cranial nerve VII, leading to altered facial sensation.
Exercise can improve circulation and cardiovascular fitness by decreasing
- A. The number of small blood vessels throughout the body
- B. The heart rate and blood pressure
- C. High-density lipoproteins (HDL) in the blood
- D. The body’s breathing capacity
Correct Answer: B
Rationale: The correct answer is B because exercise can improve circulation and cardiovascular fitness by reducing the heart rate and blood pressure. When we exercise, our heart becomes more efficient at pumping blood, leading to a lower resting heart rate and reduced blood pressure. This helps improve circulation and strengthens the cardiovascular system.
Explanation for why the other choices are incorrect:
A: The number of small blood vessels throughout the body - Exercise actually promotes the growth of new blood vessels, improving circulation.
C: High-density lipoproteins (HDL) in the blood - Exercise can increase HDL levels, which is beneficial for heart health.
D: The body’s breathing capacity - Exercise can improve lung function and increase breathing capacity, but it is not directly related to circulation or cardiovascular fitness.
Which assessment tools can be used to assess the cardiac system (select all that apply)?
- A. Watch
- B. Stethoscope
- C. Ophthalmoscope
- D. Percussion hammer
Correct Answer: D
Rationale: The correct answers are 'Watch,' 'Stethoscope,' 'Percussion hammer,' and 'Blood pressure cuff.' These tools aid in evaluating heart rate, rhythm, sounds, and vascular status.
The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.