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A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest tube should remain unclamped and disconnected from suction during transport to prevent tension pneumothorax, with the system kept below chest level.
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The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish his supply every 3 months
- B. Take one every 15 minutes if pain occurs
- C. Leave the medication in the brown bottle
- D. Crush the medication and take with water
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency.
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.
Someone sees a nursing assistant yell at an elderly client and throw his lunch tray off the table. The nursing assistant could likely be charged with
- A. negligence.
- B. assault.
- C. malpractice.
- D. battery.
Correct Answer: B
Rationale: Yelling and throwing a tray constitute assault (threatening behavior causing fear of harm). Battery involves physical contact, negligence involves failure to act, and malpractice applies to professional errors.
The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. Walk about a mile a day to prevent calcium loss.
- B. Increase the fiber in your diet.
- C. Report nausea to the doctor immediately.
- D. Drink at least eight large glasses of water a day.
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; adequate hydration (e.g., 8 glasses of water) helps prevent this.