Nokea
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select ONE that does not apply)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Pain at insertion site
- D. Sudden onset of shortness of breath
Correct Answer: A
Rationale: The correct answer is A: Production of pink sputum. Pink sputum can indicate bleeding, which is a serious complication with a mediastinal chest tube. Immediate intervention is needed to prevent further complications. Tracheal deviation (B) can indicate tension pneumothorax, requiring immediate intervention. Pain at insertion site (C) may indicate infection or dislodgement, also needing prompt attention. Sudden onset of shortness of breath (D) can suggest a pneumothorax, which requires immediate intervention as well. However, the production of pink sputum is the most critical due to the potential for severe complications like hemorrhage.
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Which biological agent has a vaccine readily available but is only used for military and at-risk civilians?
- A. Botulism
- B. Anthrax
- C. Smallpox
- D. Influenza
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A very obese female client returns to her room after abdominal surgery. The client is drowsy, but oriented; her abdominal dressing is dry and intact; and her vital signs are T 98.4, P 87, R 18, and BP 146/72. An appropriate postoperative nursing diagnosis would be:
- A. that airway clearance is ineffective.
- B. noncompliance.
- C. altered nutrition, less than her body requirements.
- D. alteration in comfort, abdominal pain.
Correct Answer: D
Rationale: The assessment information provided does not suggest a postoperative airway problem or a problem with compliance. The assessment information provided does not suggest a problem with compliance or a postoperative airway problem. While the client is obese and has altered nutrition, the nutritional problem is more than her body requirements, not less. Pain is a common phenomenon in clients who have had surgery. Postoperative pain is related to the manipulation of and the injury to tissues during the surgical procedure.
Chronic hepatitis C may be treated with
- A. Sulfasalazine.
- B. Interferon and ribavirin.
- C. Metronidazole or ciprofloxacin.
- D. Acetaminophen.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 29-year-old client is scheduled for an arthrotomy of the right knee following a football injury. The client describes his state of health as excellent and states that he does not use any medication. In providing psychological support for the client during the preoperative period, the nurse should:
- A. teach coughing and deep breathing exercises.
- B. provide for spiritual care, if appropriate.
- C. perform a head to toe assessment including height and weight.
- D. administer preoperative medication as ordered.
Correct Answer: B
Rationale: Teaching coughing and deep breathing is a component of preoperative teaching, but it does not necessarily provide psychological support. Spiritual care, a component of psychological support, can reduce the client's fears and anxieties related to the surgical experience. Performing a physical assessment is part of the physical preparation for surgery, not the psychological preparation. Providing the preoperative medication is a part of the preparation immediately before surgery. While the medication will sedate and relax the client, it is not considered to be psychological support.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
- A. Do you have trouble affording your medications?
- B. Most people with hypertension do not have symptoms.
- C. You are lucky; most people get severe morning headaches.
- D. You need to take your medicine or you will get kidney failure.
Correct Answer: B
Rationale: Step-by-step rationale:
1. Choice B is correct because it educates the client that hypertension often presents without symptoms.
2. Lack of symptoms does not mean the condition is not serious.
3. This response promotes understanding and adherence to medication.
4. Choices A, C, and D are incorrect as they do not address the main issue of hypertension being asymptomatic.