Nokea
A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Occasional bubbling in the water-seal chamber
- B. No reports of pleuritic chest pain
- C. No tidaling in the water-seal chamber
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Absence of tidaling indicates lung re-expansion as intrapleural pressure equalizes.
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A nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis due to the risk of which complication?
- A. Hyperglycemia
- B. Disequilibrium syndrome
- C. Peritonitis
- D. Hyperphosphatemia
- E. The client experiences pain upon palpation of the epigastric region.
Correct Answer: A
Rationale: Maintaining dwell time prevents excessive glucose absorption from dialysate which could cause hyperglycemia.
The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?
- A. Frequent nosebleeds and bruising
- B. Urinary retention
- C. No bowel movement in three days
- D. Increased blood glucose
Correct Answer: A
Rationale: Coagulopathy (evidenced by bleeding) is serious in cirrhosis due to impaired clotting factor production.
A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?
- A. Lactated Ringer's
- B. 0.9% sodium chloride
- C. 3% sodium chloride
- D. Dextrose 10% in water
Correct Answer: D
Rationale: D10W provides glucose to prevent hypoglycemia when TPN is interrupted.
A nurse admits a client to the emergency department who reports nausea, vomiting, and epigastric pain that worsens when lying down. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
- A. Increased serum amylase
- B. Decreased WBC count
- C. Increased serum calcium
- D. Decreased serum lipase
Correct Answer: A
Rationale: Serum amylase rises quickly in acute pancreatitis due to pancreatic inflammation.
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?
- A. Place the client in a sitting position
- B. Examine the client for areas of skin breakdown
- C. Check the client's bladder for distention
- D. Check the client for a fecal impaction
Correct Answer: A
Rationale: Sitting position lowers BP immediately by promoting venous pooling, addressing the hypertensive crisis.