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. Clamp the tube for 30 min every 8 hr.
- B. Pin the tubing to the client's bed sheets.
- C. Monitor for at least 150 mL of drainage every hour.
- D. Replace the unit when the drainage chamber is full.
Correct Answer: D
Rationale: Replacing the unit when the drainage chamber is full ensures proper function and prevents complications, such as obstruction or infection, in a closed-chest tube system.
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A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?
- A. Hypernatremia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: Heat exhaustion can lead to excessive sweating and dehydration, causing hypernatremia (elevated sodium levels) due to water loss.
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Which of the following actions should the nurse assist with?
- A. Start the prescribed antibiotic
- B. Discontinue nasogastric tube
- C. Reinforce preoperative teaching
- D. Provide the client with ice chips
Correct Answer: C
Rationale: Reinforcing preoperative teaching is appropriate given the potential need for surgery due to suspected bowel obstruction, as indicated by symptoms.
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
- A. Initiate fall precautions.
- B. Apply petroleum jelly to the client's nares.
- C. Implement contact precautions.
- D. Maintain the client in a supine position.
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, reflecting an understanding of breast self-examination teaching.
A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep-vein thrombosis?
- A. Muscle spasms
- B. Absent pedal pulse
- C. Numbness of the affected extremity
- D. Warmth of the affected extremity
Correct Answer: D
Rationale: Warmth is a classic sign of deep-vein thrombosis due to inflammation and blood flow changes in the affected area.