Nokea
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
- A. An obstruction is present in the chest tube.
- B. The client is developing subcutaneous emphysema.
- C. The chest tube system is functioning properly.
- D. There is a leak in the chest tube system.
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates a patent chest tube system, reflecting pleural pressure changes. Obstruction, emphysema, or leaks would show different signs.
You may also like to solve these questions
Which of the following positions would be appropriate for a client with severe ascites?
- A. Fowler's.
- B. Side-lying.
- C. Reverse Trendelenburg.
- D. Sims.
Correct Answer: A
Rationale: Fowler's position (A) elevates the head, reducing diaphragm pressure from ascites and improving breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective for respiratory relief.
Which symptom suggests bladder cancer recurrence?
- A. Painful urination.
- B. Frequent urination.
- C. Hematuria.
- D. Nocturia.
Correct Answer: C
Rationale: Hematuria is a common sign of bladder cancer recurrence.
The emergency department (ED) nurse cares for a client with severe intra-abdominal bleeding. The client has tachycardia, hypotension, and a thready pulse. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?
- A. Packed red blood cells (PRBCs)
- B. Platelets
- C. Granulocytes
- D. Fresh frozen plasma (FFP)
Correct Answer: A
Rationale: Severe intra-abdominal bleeding with tachycardia, hypotension, and thready pulse indicates significant blood loss, requiring PRBCs to restore oxygen-carrying capacity. Platelets, granulocytes, and FFP address other issues like clotting or infection, but PRBCs are primary for acute hemorrhage.
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
- A. Assume decision making for the client.
- B. Encourage the client's compliance with all treatment regimens.
- C. Inform the client of all possible adverse treatment effects.
- D. Identify available resources.
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.
A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply.
- A. Mailing eye examinations every 6 months.
- B. Maintaining follow-up monitoring of liver enzymes.
- C. Decreasing protein intake in the diet.
- D. Avoiding alcohol intake.
- E. The urine may have an orange color.
Correct Answer: B,D,E
Rationale: Rifampin requires liver enzyme monitoring (B) and alcohol avoidance (D) due to hepatotoxicity risk. Orange urine (E) is a harmless side effect. Eye exams and reduced protein intake are not indicated.