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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Mr. Jones is being discharged today. Which of the following statements by Mr. Jones would indicate that he understands his postoperative regimen?
- A. I'm taking my nephew to the amusement park next week and we are going to ride the roller-coasters.'
- B. My brother will be coming over every day to help me with my bath and to shave me.'
- C. I think I'll watch the baseball games on TV this week rather than driving to the stadium.'
- D. I guess I'll have to take an early retirement since my job as an accountant requires me to use my eyes a lot.'
Correct Answer: C
Rationale: Avoiding strenuous activities like driving or riding roller coasters demonstrates understanding of activity restrictions necessary during recovery from retinal surgery.
A 44-year-old male client had abdominal surgery this morning. The nurse noticed a small amount of bloody drainage on the client's surgical dressing. This type of drainage is:
- A. serosanguineous.
- B. purulent.
- C. sanguineous.
- D. catarrhal.
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Purulent drainage usually indicates infection. This drainage should not be seen initially from a surgical incision. An incision with a Penrose drain may be expected to have a moderate amount of serosanguineous drainage in the first 24 hours, but in general drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
What are the factors that interfere with a client’s learning capacity? How can receptiveness to learning be increased?
- A. Stress,fatigue and lack of interest; create a supportive environment.
- B. Lack of resources; provide more materials.
- C. Cultural differences; adapt teaching methods.
- D. None of the above.
Correct Answer: A
Rationale: Factors like stress and fatigue hinder learning. Creating a supportive, stress-free environment enhances receptiveness.
While recovering from the anesthetic, what is the best position for Mrs. West?
- A. Supine with legs fully extended
- B. Prone with head turned to the side
- C. Lateral Sims with legs flexed
- D. Trendelenburg with head to the side
Correct Answer: D
Rationale: The correct answer is D: Trendelenburg with head to the side. This position helps prevent aspiration by promoting drainage of secretions from the mouth and reducing the risk of airway obstruction. Placing the patient in Trendelenburg position with the head to the side also helps facilitate proper blood flow and ventilation. Supine with legs fully extended (A) may increase the risk of airway obstruction and aspiration. Prone with head turned to the side (B) may obstruct the airway and hinder breathing. Lateral Sims with legs flexed (C) is not suitable for a patient recovering from anesthesia as it may not provide optimal airway clearance and respiratory support.
Which complications are related to anorexia nervosa?
- A. Premature wrinkles
- B. Vitamin excess
- C. Stress fractures in spine or hip
- D. Fluid overload
Correct Answer: C
Rationale: Severe weight loss weakens bones, increasing the risk of stress fractures in weight-bearing areas like the spine and hips.