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A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
- A. The tube will drain fluid from your chest.'
- B. The tube will remove excess air from your chest.'
- C. The tube controls the amount of air that enters your chest.'
- D. The tube will seal the hole in your lung.'
Correct Answer: B
Rationale: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
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A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
- A. Diaphoresis with decreased urinary output
- B. Increased heart rate with increased respirations
- C. Improved respiratory status and increased urinary output
- D. Decreased chest pain and decreased blood pressure
Correct Answer: C
Rationale: Improved respiratory status and increased urinary output. Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI disturbances.
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine. Protamine binds heparin, making it ineffective.
The nurse completed discharge teaching for the client with sutures in place after a skin biopsy. Which statements by the client indicate an understanding of the teaching? Select all that apply.
- A. "The incision should be clean, dry, and not separated."
- B. "I will return in 2 to 3 days to have the stitches removed."
- C. "If I have an elevated temperature, I'll contact my provider."
- D. "I'll keep the bandage on for a week before I check the incision."
- E. "Excessive redness, pain, or drainage may mean it is infected."
Correct Answer: A,C,E
Rationale: A: Clean, dry, intact incisions indicate proper care. C: Fever suggests infection, requiring follow-up. E: Redness, pain, or drainage are infection signs. B: Sutures are removed in 7-10 days. D: Incisions should be checked daily.
The hospitalized client has protective precautions (reverse isolation) in place because of severe neutropenia. Which statement by the nurse to the NA is correct regarding the use of protective precautions?
- A. "You should don gloves as soon as you enter the client's room."
- B. "Minimize the amount of time the client spends outside the room."
- C. "The client needs to be moved to a private room with negative air pressure."
- D. "Everyone entering the client's room should be sure to put on a mask."
Correct Answer: B
Rationale: B: Minimizing time outside the room reduces pathogen exposure. A, D: Gloves and masks are not required unless infection is present. C: Positive, not negative, air pressure is needed.
The charge nurse is assigning staff to care for the client with disseminated herpes zoster. Which staff member should the charge nurse exclude from being assigned?
- A. A 7-month pregnant nurse who had confirmed chicken pox in childhood
- B. A 32-year-old nurse with unknown disease or vaccination history for chicken pox
- C. A 28-year-old nurse with a history of varicella vaccine and 2 small children at home
- D. A 60-year-old nurse with a history of live herpes zoster vaccine
Correct Answer: B
Rationale: B: Unknown immunity status poses a risk of varicella infection. A, C, D: These staff have immunity via prior infection or vaccination.