Nokea
A mother reports to the nurse that she cannot afford the antibiotic azithromycin (Zithromax), which was ordered by the physician for her toddler's ear infection. Which of the following is the most appropriate action by the nurse?
- A. Instruct the mother on the importance of the medication
- B. Ask the mother if she knows anyone who could loan her the money
- C. Confer with the physician about whether a less expensive drug could be ordered
- D. Consult with the social worker
Correct Answer: C
Rationale: Conferring with the physician to explore a less expensive alternative medication addresses the mother's financial concern while ensuring treatment. Instructing on importance doesn't solve affordability, asking about loans is inappropriate, and a social worker may help later but isn't the first step.
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The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Absence of tidaling in the water seal chamber.
- C. Fluctuation of fluid in the drainage tube with respiration.
- D. No drainage in the collection chamber.
Correct Answer: C
Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.
Select the member of the multidisciplinary team that you would most likely collaborate with when the client can benefit from the use of adaptive devices for cutting food?
- A. The physical therapist
- B. The occupational therapist
- C. The dietician
- D. The podiatrist
Correct Answer: B
Rationale: An occupational therapist specializes in helping clients use adaptive devices to perform activities of daily living, such as cutting food, making them the most appropriate team member for this need.
The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Tubing clamped near the insertion site.
- C. Chest tube secured to the chest wall.
- D. Suction set at 20 cm H2O.
Correct Answer: B
Rationale: Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
- A. Remove the inner cannula every 2 hours for cleaning.
- B. Secure the tracheostomy ties with a square knot.
- C. Use cut gauze under the neck plate to protect the skin.
- D. Suction the inner cannula on completion of the procedure.
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
The nurse is developing a community health education program about sexually transmitted diseases. Which information about women who acquire gonorrhea should be included?
- A. Women are more reluctant than men to seek medical treatment.
- B. Gonorrhea is not easily transmitted to women who are menopausal.
- C. Women with gonorrhea are usually asymptomatic.
- D. Gonorrhea is usually a mild disease for women.
Correct Answer: C
Rationale: Women with gonorrhea are often asymptomatic, which increases the risk of delayed treatment and complications, a key point for education.