Nokea
A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?
- A. Notify the physician.
- B. Clamp the chest tube.
- C. Replace the system.
- D. Document the finding.
Correct Answer: D
Rationale: Gentle bubbling is a normal finding for the client who has a pleural drainage system to suction, so it simply needs to be documented. If the bubbling becomes vigorous, it could indicate a leak, which the nurse needs to investigate. The remaining choices are not necessary.
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A 46 year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
- A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
- B. Allow the patient to begin limited ambulation with assistance.
- C. Recommend a physical therapy consultation for ambulation.
- D. Tell the patient to remain with leg straight for another 6 hours and check the chart for activity orders.
Correct Answer: A
Rationale: The patient should keep the leg straight for at least 4 hours.
Which medication might the physician order if the client expresses discomfort with being in the enclosed space of a CT scanner?
- A. Valium (diazepam)
- B. Clozaril (clozapine)
- C. Catapress (clonidine)
- D. Lasix (furosemide)
Correct Answer: A
Rationale: Valium, a sedative, is appropriate to reduce anxiety and discomfort in a confined CT scanner, unlike the other medications, which have different indications.
Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:
- A. outbreak of Asian flu.
- B. Chemical exposure.
- C. bacterial pneumonia.
- D. allergic reaction.
Correct Answer: B
Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure.
A Hispanic client brings her father to the clinic because he is becoming more forgetful. He is diagnosed with Alzheimer's disease. The woman tells the nurse that she wants to try ginkgo biloba for her father, before using prescription medications. Which of the following is an appropriate response by the nurse?
- A. It is wiser to start a prescription
- B. That herb won't do your father any good
- C. You can't expect an herb to treat Alzheimer's
- D. I will let the physician know of your wishes
Correct Answer: D
Rationale: The culturally sensitive response is to notify the physician of the family member's wishes and to determine whether it is feasible. Ginkgo biloba has been shown to be of some benefit in treating dementia. The other statements are not culturally sensitive.
A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of?
- A. positive
- B. false positive
- C. negative
- D. false negative
Correct Answer: B
Rationale: A false positive occurs when a test incorrectly indicates a disease is present, potentially leading to unnecessary treatment or anxiety.