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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: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CDC). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.
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A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
- A. Use a fire extinguisher at the source of the smoke.
- B. Close the doors to the room and to the bathroom.
- C. Activate the fire alarm system.
- D. Assist the client to a nearby common area.
Correct Answer: D
Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Advise the client about increased dry mouth.
- B. Monitor the client for weight loss.
- C. Inform the client of the adverse effect of diarrhea.
- D. Check the client for increased hypopigmentation under the patch.
- E. Monitor for hypertension.
- F. Advise about insomnia.
- G. Check for tachycardia.
Correct Answer: A
Rationale: Dry mouth is a common side effect of clonidine; diarrhea and hypopigmentation aren't typical.
A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
- A. Nerve damage
- B. Infection
- C. Infiltration
- D. Phlebitis
Correct Answer: C
Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue. Infection involves warmth/redness, phlebitis includes inflammation, and nerve damage affects sensation/movement.
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Blood pressure dropping to 86/50 mm Hg from 118/78 signals hypotension, risking organ perfusion a circulation priority per ABCs. Heart rate falling to 68 from 110 may normalize post-tachycardia, less urgent without distress. Respiratory rate rising to 20 from 12 suggests compensation, but hypotension trumps breathing acuity. Fever at 38.8°C indicates infection, but hemodynamic instability is more immediate shock or bleeding needs rapid action. This finding drives urgent assessment (e.g., fluids, vasopressors), aligning with triage protocols, making it the nurse's top concern.
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Limit the client's physical activity until bowel continence is achieved.
- B. Assist the client to the restroom 30 min after meals.
- C. Instruct the client to limit their intake of high-fiber foods.
- D. Limit the client's fluid intake to 1500 mL/day
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.