Nokea
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. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.
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A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
- A. Depress the canister after you inhale.'
- B. Exhale fully before bringing the inhaler to your lips.'
- C. Use peroxide to clean the mouthpiece of your inhaler.'
- D. Do not shake your inhaler before use.'
Correct Answer: B
Rationale: The correct answer is B: "Exhale fully before bringing the inhaler to your lips." This statement is important because exhaling fully before inhaling the medication helps to ensure maximum delivery of the medication into the lungs. By exhaling fully, the client creates more space in the lungs for the medication to reach the lower airways effectively.
Choice A is incorrect because depressing the canister after inhaling would not allow the medication to reach the lungs. Choice C is incorrect as peroxide is not recommended for cleaning inhaler mouthpieces. Choice D is incorrect because shaking the inhaler before use is necessary to ensure proper mixing of the medication for effective delivery.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
- A. Measure blood pressure.
- B. Administer aspirin.
- C. Administer nitroglycerin.
- D. Initiate IV access.
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Administering aspirin is the priority action for a client with acute angina as it helps in reducing platelet aggregation and improving blood flow to the heart. This action can potentially prevent further clot formation and decrease the risk of a heart attack. It is essential to address the acute symptoms first before proceeding with other interventions. Measuring blood pressure (A), administering nitroglycerin (C), and initiating IV access (D) are important actions but administering aspirin takes precedence in this scenario to address the acute angina symptoms promptly.
A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will increase the amount of fresh fruits and vegetables I consume.'
- B. I will need to take my clothes to the dry cleaners to sterilize them.'
- C. I will be sure to wear gloves and wash my hands when I change my cat's litter box.'
- D. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash.'
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Using alcohol to wipe up areas soiled with body fluids helps to disinfect the surfaces, reducing the risk of infection spread.
2. Immediately disposing of the trash containing body fluids prevents further exposure to infectious materials.
3. This statement demonstrates understanding of infection control measures crucial for someone with AIDS.
Incorrect Choices:
A: Increasing fresh fruits and vegetables is a healthy choice but not directly related to preventing infection spread in the context of AIDS.
B: Taking clothes to the dry cleaners for sterilization is unnecessary and does not address infection control.
C: Wearing gloves and washing hands when changing a cat's litter box is a good hygiene practice but not specific to preventing transmission of HIV.
A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowler’s position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.