Nokea
A nurse is assessing a client who has a chest tube. 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 control chamber.
- C. Tidaling in the water seal chamber.
- D. Drainage of 75 mL in the first 24 hours.
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.
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A nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the nurse take?
- A. Check for residual feeding contents.
- B. Administer the feeding through a large-bore syringe.
- C. Flush the tube with 10 mL of water after feeding.
- D. Administer the feeding at room temperature.
Correct Answer: C
Rationale: The correct action for the nurse to take when preparing to administer an intermittent enteral feeding through a nasogastric tube is to flush the tube with 10 mL of water after feeding. This helps maintain tube patency and prevent clogging. Choice A, checking for residual feeding contents, is not the immediate action to take before administering the feeding. Choice B, administering the feeding through a large-bore syringe, is not the recommended method for administering enteral feedings. Choice D, administering the feeding at room temperature, is important but not the immediate action related to tube maintenance.
A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?
- A. The oxygen should be kept in a storage room when not in use.
- B. Turn off the oxygen when not in use.
- C. Check the oxygen level regularly using a pulse oximeter.
- D. Never leave the oxygen running when transporting a client.
Correct Answer: C
Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.
A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?
- A. "You can take this medication with a full glass of water."
- B. "You should store this medication in the refrigerator."
- C. "Take one tablet every 5 minutes until the pain is relieved, up to three doses."
- D. "You should avoid eating foods high in sodium while taking this medication."
Correct Answer: C
Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.
A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid using aspirin for pain.
- B. I will consume dairy products to increase my calcium intake.
- C. I will drink 1.5 to 2 liters of fluid each day.
- D. I will need to limit my intake of fiber.
Correct Answer: A
Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?
- A. Diabetes mellitus
- B. Shoulder presentation
- C. Postterm with oligohydramnios
- D. Chorioamnionitis
Correct Answer: B
Rationale: Shoulder presentation is a contraindication for oxytocin because it can increase the risk of complications during labor, such as shoulder dystocia. Diabetes mellitus (Choice A) is not a contraindication for the use of oxytocin. Postterm with oligohydramnios (Choice C) and chorioamnionitis (Choice D) may actually necessitate the use of oxytocin to induce or augment labor for the well-being of the mother and baby.