Nokea
A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed?
- A. Butterfly dressing.
- B. Montgomery strap.
- C. Fine-mesh gauze dressing.
- D. Petroleum gauze dressing.
Correct Answer: D
Rationale: Petroleum gauze creates an airtight seal over the chest tube site, preventing air entry into the pleural space. Other dressings are less occlusive.
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A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?
- A. With two people at each side using a drawsheet.
- B. With two people, one at each side using a drawsheet, and one person at the head.
- C. With two people using a roller and a drawsheet.
- D. With two people, one at each side using a drawsheet, one person at the head, and one person at the feet.
Correct Answer: B
Rationale: Using a drawsheet with two people (one per side) and one at the head minimizes skin shearing by providing support and controlled movement, suitable for a drowsy elderly client.
The nurse should instruct the client to avoid which of the following drugs while taking metoclopramide hydrochloride (Reglan)?
- A. Antihypertensives.
- B. Anticoagulants.
- C. Alcohol.
- D. Cimetidine.
Correct Answer: C
Rationale: Alcohol can enhance the sedative effects of metoclopramide and worsen gastrointestinal symptoms, so it should be avoided.
Which of the following techniques for administering the Mantoux test is correct?
- A. Hold the needle and syringe almost parallel to the client's skin.
- B. Pinch the skin when inserting the needle.
- C. Aspirate before injecting the medication.
- D. Massage the site after injecting the medication.
Correct Answer: A
Rationale: The Mantoux test requires intradermal injection, with the needle held almost parallel to the skin to form a wheal. Pinching, aspirating, or massaging disrupts the test's accuracy.
A client with Ménière'sdisease continues to have disabling attacks of vertigo and elects to have a labyrinthectomy. A priority nursing diagnosis for the client before surgery is:
- A. Deficient diversional activity related to inability to participate secondary to vertigo.
- B. Risk for injury related to vertigo.
- C. Powerlessness related to inability to influence effects of disease process.
- D. Social isolation related to hearing loss.
Correct Answer: B
Rationale: Risk for injury related to vertigo is the priority due to the high risk of falls and accidents during vertigo attacks, which is a significant concern pre-surgery.
The nurse is caring for a client with acute arterial occlusion of the left lower extremity. To prevent further tissue damage, it is important for the nurse to observe for which of the following:
- A. Blood pressure and heart rate changes
- B. Gradual or acute loss of sensory and motor function
- C. Metabolic acidosis
- D. Swelling in the left lower extremity
Correct Answer: B
Rationale: Acute arterial occlusion causes ischemia, leading to loss of sensory (numbness) and motor function (weakness) in the affected limb. Monitoring for these changes is critical to detect progression and prevent tissue damage. Blood pressure/heart rate, metabolic acidosis, and swelling are less specific or late findings.