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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The role of the incident report in risk management is:
- A. liability protection.
- B. to provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. to discipline staff for errors.
- D. all of the above.
Correct Answer: B
Rationale: Incident reports are a tool for determining how future problems can be avoided. Incident reports do not provide liability protection. Incident reports are not meant to be used for disciplining staff.
The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
- A. Place the client in the waiting room until an available cubicle is open
- B. Seclude the client from other clients and visitors
- C. Perform no intervention because it might not be necessary until tests confirm a disease
- D. Don gown, gloves, and mask immediately
Correct Answer: B
Rationale: Symptoms suggestive of tuberculosis require immediate seclusion to prevent transmission, with caregivers using respirator masks.
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.
Which of the following foods might a client with a hypercholesterolemia need to decrease his or her intake of?
- A. broiled catfish
- B. hamburgers
- C. wheat bread
- D. fresh apples
Correct Answer: B
Rationale: Due to the high cholesterol content of red meats, such as hamburger, intake needs to be decreased. The other options do not have high cholesterol content, so they do not need to be decreased.
Which type of dressing is recommended to place over a site when a chest tube is removed by the physician?
- A. transparent dressing
- B. colloidal dressing
- C. petrolatum gauze
- D. nonadherent dressing
Correct Answer: C
Rationale: Petrolatum gauze is recommended to place over a site when a chest tube is removed by the physician. This is because it forms an airtight seal, which the other choices do not.