Nokea
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
- A. Your breathing pattern causes this.'
- B. This means your lung is fully re-expande '
- C. Suction pressure that is too high causes this.'
- D. This indicates a possible air leak.'
Correct Answer: A
Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system. Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber. Choice B is incorrect as lung re-expansion does not directly cause the fluid movement. Choice C is incorrect as high suction pressure does not cause this specific phenomenon. Choice D is incorrect as fluid movement does not indicate an air leak.
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Which of the following actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increase in dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure. Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.
A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
- A. The client moves the cane 2 feet ahea
- B. The client advances the weaker leg forward to the cane.
- C. The client takes a step with their right foot first.
- D. The client holds the cane with their left han
Correct Answer: B
Rationale: The correct answer is B. Advancing the weaker leg forward to the cane provides stability and support, helping distribute weight evenly and preventing falls. This step is crucial in using a quad cane effectively. Moving the cane too far ahead (A) could cause imbalance. Taking a step with the stronger leg first (C) would not provide the needed support for the weaker side. Holding the cane with the same side as the weakness (D) may not provide the necessary support. It is essential to prioritize stability and weight distribution, making option B the correct choice.
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?
- A. Access the catheter using a non-coring needle.
- B. Change the transparent membrane dressing daily.
- C. Maintain a continuous IV infusion through the PICC line.
- D. Flush the catheter with a 0.9% sodium chloride solution after each use.
Correct Answer: D
Rationale: Correct Answer: D - Flush the catheter with a 0.9% sodium chloride solution after each use.
Rationale: Flushing the catheter with 0.9% sodium chloride solution after each use helps prevent clot formation, maintains patency, and ensures proper functioning of the PICC line. This action also helps prevent infection and occlusions.
Incorrect Choices:
A: Accessing the catheter using a non-coring needle is not necessary for routine care of a PICC line.
B: Changing the transparent membrane dressing daily may increase the risk of infection and disrupt the integrity of the dressing.
C: Maintaining a continuous IV infusion through the PICC line is not indicated for a client receiving intermittent IV bolus antibiotics.
E, F, G: No additional choices provided.
A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
- A. Limit fluid intake to 1,000 mL per day.
- B. Administer oxygen at 2 L/min.
- C. Encourage use of incentive spirometry for 5 min every 2 hr.
- D. Teach the client a breathing exercise with a longer inhalation phase.
Correct Answer: D
Rationale: The correct answer is D. Teaching the client a breathing exercise with a longer inhalation phase helps improve lung capacity and strengthen respiratory muscles, which are essential for clients with emphysema. This intervention can help the client breathe more effectively and reduce shortness of breath. Option A is incorrect because limiting fluid intake is not a standard intervention for emphysema. Option B is incorrect as administering oxygen is not specific to improving lung function. Option C is incorrect as incentive spirometry is more effective if done for longer durations.
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform strength-building arm exercises using a 15-pound weight.'
- B. I should expect less than 25 mL of secretions per day in the drainage devices.'
- C. I will have to wait 2 months before additional saline can be added to my breast expander.'
- D. I will keep my left arm flexed at the elbow as much as possible.'
Correct Answer: B
Rationale: The correct answer is B: "I should expect less than 25 mL of secretions per day in the drainage devices." This demonstrates an understanding of the need to monitor drainage postoperatively. Excessive drainage can indicate complications like infection or bleeding.
A: Performing strength-building exercises with a 15-pound weight is contraindicated postoperatively as it can strain the surgical site.
C: Waiting 2 months before adding saline to the expander is incorrect. Saline can be added gradually postoperatively.
D: Keeping the left arm flexed at the elbow is not recommended as it can lead to stiffness and limited range of motion.