Nokea
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
- A. Check the tubing to ensure that the client is not lying on it or kinking it.
- B. Increase the suction.
- C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
- D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
You may also like to solve these questions
A client in a hospice program has increasing pain. The nurse and client collaborate to schedule analgesics to provide which of the following?
- A. Doses of analgesic when pain is a '5' on a scale of 1-10.
- B. Enough analgesia to keep the client semisomnolent.
- C. An analgesia-free period so that the client can carry out daily hygienic activities.
- D. Around-the-clock routine administration of analgesics for continuous pain relief.
Correct Answer: D
Rationale: Around-the-clock administration of analgesics ensures continuous pain relief, which is critical for hospice patients with persistent pain, preventing pain escalation.
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.
Doxorubicin (Adriamycin) is prescribed for a female client with breast cancer. The client is distressed about hair loss. The nurse should do which of the following?
- A. Have the client wash and massage the scalp daily to stimulate hair growth.
- B. Explain that hair loss is temporary and will quickly grow back to its original appearance.
- C. Provide resources for a wig selection before hair loss begins.
- D. Recommend that the client limit social contacts until hair regrows.
Correct Answer: C
Rationale: Providing resources for wig selection before hair loss begins helps the client prepare for and cope with chemotherapy-induced alopecia, maintaining her self-esteem.
Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma?
- A. Cough productive of yellow sputum.
- B. Bilateral expiratory wheezing.
- C. Chest tightness.
- D. Respiratory rate of 30 breaths/minute.
Correct Answer: A
Rationale: A productive cough with yellow sputum suggests a respiratory infection, which can exacerbate asthma. Wheezing, chest tightness, and tachypnea are typical asthma symptoms, not specific to infection.