Nokea
A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?
- A. Respiratory rate greater than 16 breaths/minute.
- B. Continuous bubbling in the water-seal chamber.
- C. Fluid in the chest tube.
- D. Fluctuation of fluid in the water-seal chamber.
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, requiring physician notification. A respiratory rate >16 is normal. Fluid in the tube and fluctuation are expected.
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For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy?
- A. Acromegaly.
- B. Cushing's disease.
- C. Diabetes mellitus.
- D. Hypopituitarism.
Correct Answer: D
Rationale: Hypophysectomy can impair pituitary function, leading to hypopituitarism, with symptoms like fatigue, weakness, and hormonal deficiencies.
Which of the following terms describes the condition of a client with the disease in dosage to maintain adequate analgesia?
- A. Pseudoaddiction.
- B. Physical dependence.
- C. Psychological dependence.
- D. Drug tolerance.
Correct Answer: D
Rationale: Drug tolerance occurs when a client requires increased doses to maintain analgesia due to the body's adaptation to the medication.
A client has sudden, severe pain in his back and chest, accompanied by shortness of breath. The client describes the pain as a 'tearing' sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The code cart is brought into the room because one complication of a dissecting aneurysm is:
- A. Cardiac tamponade
- B. Stroke
- C. Pulmonary edema
- D. Myocardial infarction
Correct Answer: A
Rationale: A dissecting aortic aneurysm can rupture into the pericardial space, causing cardiac tamponade, a life-threatening complication requiring emergency intervention (hence the code cart). Stroke, pulmonary edema, and myocardial infarction are less common or indirect complications.
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.