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A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. This finding indicates an air leak in the system, which can compromise the client's respiratory status. The continuous bubbling signifies that air is escaping through the chest tube rather than being properly drained. The nurse should report this to the provider immediately for further evaluation and intervention to prevent pneumothorax or other complications.
The other choices (B, C, D) are incorrect because intermittent bubbling in the suction chamber is expected as it indicates proper functioning of the system. Clear drainage of 50 mL over 8 hours is within normal limits and does not pose an immediate threat to the client. Mild pain at the insertion site is also a common finding after chest tube insertion and does not require urgent intervention unless it worsens or is accompanied by other concerning symptoms.
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A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will place my used tissues in a plastic bag.
- B. I will share my utensils with my family.
- C. I will not need to wear a mask at home.
- D. I will stop taking my medications when I feel better.
Correct Answer: A
Rationale: The correct answer is A: "I will place my used tissues in a plastic bag." This statement indicates understanding of infection control for tuberculosis by properly disposing of contaminated materials to prevent the spread of the disease. Placing used tissues in a plastic bag helps contain the bacteria.
Choices B, C, and D are incorrect:
B: Sharing utensils can spread the infection to family members.
C: Not wearing a mask at home can expose others to the bacteria.
D: Stopping medications prematurely can lead to treatment failure and drug resistance.
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
- A. Rapid pulse rate
- B. Bradycardia
- C. Hypertension
- D. Peripheral edema
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse rate. Following surgery, hypovolemia can occur due to fluid loss. A rapid pulse rate is a common manifestation of hypovolemia as the body compensates for decreased blood volume by increasing heart rate to maintain perfusion. Bradycardia (B) is unlikely with hypovolemia as the body tries to increase cardiac output. Hypertension (C) is not typical in hypovolemia as blood pressure tends to decrease. Peripheral edema (D) is associated with fluid overload, not hypovolemia.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (A) reduces exposure to infectious agents. Taking temperature daily (C) helps detect early signs of infection. Washing toothbrush weekly (B) is important but daily is recommended. Eating fresh fruits and vegetables (D) is beneficial but may pose infection risk.
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowlers position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area. Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine. Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.
A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take?
- A. Inspect the pin sites at least every 8 hr.
- B. Apply direct pressure to pin sites.
- C. Remove traction weights for comfort.
- D. Encourage vigorous movement of the affected limb.
Correct Answer: A
Rationale: Correct Answer: A. Inspect the pin sites at least every 8 hr.
Rationale:
1. Inspecting pin sites regularly is crucial to monitor for signs of infection or other complications.
2. Postoperative clients with skeletal traction are at high risk for pin site infections.
3. Regular inspection allows early detection and intervention to prevent complications.
4. Waiting longer than every 8 hours may lead to delayed identification of issues.
Summary:
B. Applying direct pressure is contraindicated as it can cause harm.
C. Removing traction weights without medical order can lead to complications.
D. Encouraging vigorous movement is inappropriate and can cause harm.