Nokea
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
- A. Clear breath sounds on the affected side
- B. Reduction in drainage output
- C. Development of subcutaneous emphysema
- D. Minimal pain at the surgical site
Correct Answer: C
Rationale: Subcutaneous emphysema, where air gets trapped under the skin, may indicate an underlying pneumothorax and should be reported to the provider.
You may also like to solve these questions
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
- A. Serum creatinine
- B. Serum potassium
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Creatinine is a waste product produced by muscles and filtered out by the kidneys. In clients with SLE, renal involvement is common. Elevated serum creatinine levels indicate impaired renal function, as the kidneys are not effectively filtering out waste products. Monitoring serum creatinine levels helps assess renal function and detect kidney damage early.
Choices B, C, D, and E are incorrect as they do not directly reflect renal function. Serum potassium levels (B) are more indicative of electrolyte balance, white blood cell count (C) indicates immune response, and hemoglobin level (D) reflects oxygen-carrying capacity.
A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client?
- A. Postmenopausal bleeding
- B. Weight loss
- C. Increased appetite
- D. Abnormal hair growth
Correct Answer: A
Rationale: The correct answer is A: Postmenopausal bleeding. Endometrial cancer commonly presents with postmenopausal bleeding as a key manifestation due to abnormal growth of the endometrial tissue. This occurs because the cancerous cells disrupt the normal shedding process of the endometrium, leading to bleeding after menopause. Weight loss (B) is often associated with advanced stages of cancer, but it is not a specific early manifestation of endometrial cancer. Increased appetite (C) and abnormal hair growth (D) are not typically associated with endometrial cancer.
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?
- A. Paraplegia
- B. Tetraplegia
- C. Quadriplegia
- D. Hemiplegia
Correct Answer: A
Rationale: The correct answer is A: Paraplegia. Damage at the T2-T3 vertebrae level affects the lower part of the body, resulting in paralysis of the legs and potentially part of the trunk (paraplegia). This injury does not affect the arms or hands, ruling out tetraplegia (B) and quadriplegia (C). Hemiplegia (D) refers to paralysis on one side of the body only, which is not the case here. Other choices are not applicable.
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
- A. Give the ordered KCL as prescribed.
- B. Hold the KCL and notify the healthcare provider.
- C. Administer potassium via IV push.
- D. Check the client's potassium level again in 1 hour.
Correct Answer: A
Rationale: The correct answer is A: Give the ordered KCL as prescribed. The nurse should administer potassium chloride as prescribed because the client's potassium level of 3.2 mEq/L is within the normal range (3.5-5.0 mEq/L). Potassium chloride is indicated for clients with hypokalemia (low potassium levels), and the client's level falls within the normal range, so administering the ordered KCL is appropriate. Holding the KCL is unnecessary since the potassium level is not critically low. Administering potassium via IV push is not indicated as the client's potassium level is not critically low. Checking the client's potassium level again in 1 hour is unnecessary as the level is already within the normal range.
A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?
- A. Obtain a sputum culture
- B. Administer a chest X-ray
- C. Monitor for fever
- D. Provide oxygen therapy
Correct Answer: A
Rationale: The correct answer is A: Obtain a sputum culture. This is essential to identify the specific pathogen causing the pneumonia in the client with AIDS. By identifying the pathogen, appropriate antibiotic therapy can be initiated promptly. Administering a chest X-ray (B) may help in evaluating the extent of pneumonia but does not address the underlying cause. Monitoring for fever (C) is important but does not provide specific information needed for targeted treatment. Providing oxygen therapy (D) may be necessary but does not address the root cause of the pneumonia.