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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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Which of the following is not a reason for pelvic ultrasonography?
- A. to measure uterine size
- B. to detect multiple pregnancies
- C. to measure renal size
- D. to detect foreign bodies
Correct Answer: C
Rationale: Pelvic ultrasonography assesses pelvic organs, not renal size, which is evaluated via abdominal or renal ultrasonography.
Which of the following statements indicates adequate dietary understanding in a client with constipation?
- A. I should decrease my intake of fluids.
- B. I should decrease my level of activity.
- C. I should increase my intake of apples.
- D. I should increase my intake of milk.
Correct Answer: C
Rationale: Apples are a source of high fiber, which decreases constipation. A constipated client needs to increase fluids and activity level. Milk is not a high-fiber food.
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.