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A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:
- A. reinforce the dressing.
- B. continue to monitor the dressing.
- C. notify the physician.
- D. note the time and amount of blood.
Correct Answer: C
Rationale: The dressing should not be reinforced without notifying the physician. The physician may decide to reinforce the dressing after assessing the amount of bleeding. Blood on the dressing is unusual, which should alert the nurse to do more than monitor the dressing. The physician should be notified immediately. If the bleeding persists, the client may need to return to surgery. The time and amount of blood needs to be recorded, but only after the physician is notified.
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What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.
What goal assumes the highest priority for Ms. Weeze with an acute asthmatic attack?
- A. Preventing future attacks
- B. Maintaining quiet, restful environment
- C. Observing for signs of drug toxicity
- D. Relieving bronchial spasm
Correct Answer: D
Rationale: Relieving bronchospasm is critical to restore adequate airflow.
When assessing the health beliefs and practices of an older Hispanic adult, the nurse observes that the client uses a traditional folk healer to manage health problems. How would you respond?
- A. Respectfully acknowledge the practice and integrate it where possible.
- B. Discredit the folk healer's methods.
- C. Insist on conventional medical treatment only.
- D. Ignore the client's preference.
Correct Answer: A
Rationale: Respecting and integrating traditional practices fosters trust and collaboration in care delivery.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks.
1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system.
2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue.
3. This helps maintain the integrity of the closed chest drainage system and prevent complications.
Other choices are incorrect:
B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system.
C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician.
D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.
Identify the specific component of acquiring cultural competence reflected in creating a safe environment in which collection of relevant cultural data can be obtained during the health history and physical examination.
- A. Cultural skill
- B. Cultural encounter
- C. Cultural awareness
- D. Cultural knowledge
Correct Answer: A
Rationale: Creating a safe environment involves using cultural skills to gather accurate and meaningful cultural data during assessments.