Nokea
A client's chest tube insertion site has crepitus (crackling sensation) upon palpation. What is the nurse's next step?
- A. Apply a pressure dressing to the chest tube site.
- B. Administer an oral antihistamine.
- C. Assess the client for allergies to cleaning agents.
- D. Measure the area of swelling and crackling.
Correct Answer: D
Rationale: The correct next step for the nurse is to measure the area of crepitus. Crepitus indicates subcutaneous emphysema, which is a serious condition requiring monitoring. Applying a pressure dressing (Choice A) could worsen the condition by trapping air under the skin. Administering an oral antihistamine (Choice B) is not indicated for crepitus. Assessing for allergies to cleaning agents (Choice C) is not the priority when dealing with crepitus and subcutaneous emphysema.
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A client is admitted with a large pleural effusion. Which procedure should the nurse prepare the client for?
- A. Thoracentesis.
- B. Endotracheal intubation.
- C. Chest tube insertion.
- D. Bronchoscopy.
Correct Answer: A
Rationale: Corrected Rationale: The correct procedure for a client with a large pleural effusion is thoracentesis. Thoracentesis is a diagnostic and therapeutic procedure used to remove fluid from the pleural space, which can help relieve symptoms associated with pleural effusion. Choice B (Endotracheal intubation) is incorrect as it is a procedure to secure the airway by placing a tube into the trachea. Choice C (Chest tube insertion) is incorrect as it is typically done to drain air or fluid from the pleural space over a longer period. Choice D (Bronchoscopy) is incorrect as it is a procedure used to visualize the airways and diagnose lung conditions, not specifically for pleural effusion removal.
The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?
- A. Localized warmth
- B. Calf pain
- C. Swelling in the affected leg
- D. Hematuria
Correct Answer: D
Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.
The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?
- A. Flush the tube with water every 4 hours
- B. Check the tube placement before each feeding
- C. Secure the tube to the client's nose with tape
- D. Keep the head of the bed elevated at 30 degrees
Correct Answer: B
Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.
A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?
- A. Administer antiemetics to reduce nausea.
- B. Obtain a list of the client's cardiac medications.
- C. Perform an ECG to evaluate heart function.
- D. Review the client's dietary intake for possible causes.
Correct Answer: B
Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.
A female client experiences a sudden loss of consciousness and is taken to the emergency department. Initial assessment indicates her blood glucose level is critically low. Once stabilized, she reports being treated for anorexia nervosa. What intervention is most important for the nurse to include in the client's discharge plan?
- A. Encourage a high-protein, low-carbohydrate diet.
- B. Encourage her to join a group focusing on self-esteem.
- C. Schedule an outpatient psychosocial assessment.
- D. Teach relaxation techniques to manage stress.
Correct Answer: B
Rationale: Joining a group that focuses on self-esteem is the most important intervention for the nurse to include in the client's discharge plan. This can help the client address underlying emotional issues related to her anorexia nervosa and improve her mental health. Choice A is incorrect because a high-protein, low-carbohydrate diet may not address the psychological factors contributing to anorexia nervosa. Choice C is incorrect as scheduling an outpatient psychosocial assessment is important but not the most crucial intervention for discharge planning in this case. Choice D is also not the priority as teaching relaxation techniques, although beneficial, may not directly address the self-esteem and emotional issues that need to be tackled in this situation.