Nokea
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Monitor for at least 150 mL of drainage every hour.
- C. Clamp the tube for 30 min every 8 hr.
- D. Pin the tubing to the client's bed sheets.
Correct Answer: A
Rationale: Closed-chest tube systems manage pleural fluid or air, requiring patency and safety. Replacing the unit when the drainage chamber is full maintains system function overflow risks backpressure or infection, per manufacturer guidelines. Monitoring for 150 mL/hr is excessive; normal drainage tapers post-insertion, and sudden high output signals bleeding, not a routine action. Clamping the tube risks tension pneumothorax by trapping air or fluid, only done briefly under specific orders (e.g., checking for leaks). Pinning tubing to sheets prevents dislodgement but isn't the primary maintenance action. Full chamber replacement ensures continuous drainage, aligns with infection control (e.g., CDC standards), and prevents complications like lung collapse, making it the nurse's key responsibility in chest tube care.
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A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- D. Platelets 60,000/mm³ (150,000 to 400,000/mm³)
Correct Answer: D
Rationale: Liver biopsy risks bleeding due to vascularity, so platelets at 60,000/mm³ well below normal (150,000-400,000) signal thrombocytopenia, increasing hemorrhage risk. Normal bilirubin (1.0 mg/dL) and AST (34 units/L) reflect liver function, not clotting. Ammonia (55 mcg/dL) is normal, tied to encephalopathy, not biopsy safety. Low platelets impair hemostasis, often requiring transfusion or delay per procedural norms (e.g., AASLD), prioritizing safety unlike normal labs, this demands provider action, making it the critical value to report.
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
Nurses Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following instructions should the nurse include? (Client with iron deficiency anemia)
- A. Take an antacid within 30 min after medication
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C
- D. Take the medication on an empty stomach.
- E. Increase intake of milk and dairy products.
- F. Expect immediate energy improvement.
- G. Avoid green leafy vegetables.
Correct Answer: B,C,D
Rationale: Fiber prevents constipation, vitamin C enhances absorption, and empty stomach improves uptake; antacids and dairy reduce absorption.
A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Bleach
- C. Hydrogen peroxide
- D. Chlorhexidine
Correct Answer: B
Rationale: A 1:10 bleach solution is the standard for decontaminating blood spills in AIDS care, effectively killing HIV. Other agents are less effective against bloodborne pathogens.
A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching?
- A. Physical inactivity
- B. Family history of colorectal cancer
- C. High-fiber diet
- D. Age over 50 years
- E. History of diabetes mellitus
Correct Answer: B
Rationale: Colorectal cancer risk factors are well-documented, with family history being a major non-modifiable contributor due to genetic predisposition (e.g., Lynch syndrome). Physical inactivity increases risk by slowing bowel motility, allowing carcinogen exposure, but it's less definitive than genetics. A high-fiber diet reduces risk by promoting regular bowel movements, not increasing it, so it's incorrect here. Age over 50 is a strong risk factor as incidence rises with age, but family history often trumps it in teaching specificity due to its hereditary link. Emphasizing family history educates the client on screening needs (e.g., earlier colonoscopy), aligning with guidelines like those from the American Cancer Society. It's a critical, actionable factor, driving personalized prevention and surveillance, making it a standout choice for inclusion in teaching.
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
- A. Jaundice
- B. Muscle rigidity
- C. Weight loss
- D. Easily bruised
Correct Answer: D
Rationale: Easy bruising is expected in Cushing's syndrome due to excess cortisol thinning the skin and weakening blood vessels. Jaundice, rigidity, and weight loss are not typical.