Nokea
A client in ICU has a chest tube, and the nurse is assessing the chest tube drainage system. The nurse notices intermittent bubbling in the water seal chamber. What action should the nurse take?
- A. clamp the chest tube and call for help
- B. document the findings in the client chart
- C. document an air leak and notify the physician
- D. call the physician to report the findings
Correct Answer: B
Rationale: Intermittent bubbling in the water seal chamber is normal during inspiration/expiration or coughing, indicating a patent system. It should be documented as a normal finding.
You may also like to solve these questions
The nurse is assessing a client who is 36 hours postpartum. Which of the following findings would indicate a need for further evaluation?
- A. Fundus firm and 2 cm below the umbilicus.
- B. Moderate lochia serosa.
- C. Mild perineal discomfort.
- D. Temperature of 100.4°F (38°C).
Correct Answer: D
Rationale: a temperature of 100.4°F may indicate infection, such as endometritis, and requires further evaluation
A nurse is floated to oncology from the postsurgical floor. The assigned client is almost finished with an infusion of doxorubicin for breast cancer. The floated nurse is not chemotherapy certified. Which nursing action is the priority in this situation?
- A. assess the client's pain
- B. ask another nurse about side effects of the drug
- C. assess the IV site, including the date on the tubing and IV site
- D. inform the charge nurse that she is not chemotherapy certified and ask for another assignment
Correct Answer: D
Rationale: The priority is to inform the charge nurse of the lack of chemotherapy certification, as doxorubicin requires specialized handling and monitoring.
An elderly adult has been admitted with a diagnosis of hypertension with a history of dementia. Which of the following nursing diagnoses has the highest priority for this client?
- A. ineffective coping
- B. activity intolerance
- C. ineffective tissue perfusion
- D. risk for injury
Correct Answer: D
Rationale: Dementia increases fall and injury risk due to impaired judgment and memory, making 'risk for injury' the priority.
The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients is:
- A. Setting realistic limits
- B. Encouraging the client to express remorse for behavior
- C. Minimizing interactions with other clients
- D. Encouraging the client to act out feelings of rage
Correct Answer: A
Rationale: Setting realistic limits helps manage the manipulative and impulsive behaviors common in antisocial personality disorder, promoting safety and structure.
The home health nurse is visiting a client with Paget's disease. An important part of preventive care for the client with Paget's disease is:
- A. Keeping the environment free of clutter
- B. Advising the client to see the dentist regularly
- C. Encouraging the client to take the influenza vaccine
- D. Telling the client to take a daily multivitamin
Correct Answer: A
Rationale: Paget's disease increases fracture risk, so keeping the environment clutter-free reduces fall risks, a key preventive measure.