Nokea
A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider?
- A. Drainage of 75 mL in the past 24 hours.
- B. Intermittent bubbling in the water seal chamber.
- C. Continuous bubbling in the water seal chamber.
- D. Tidaling in the water seal chamber.
Correct Answer: C
Rationale: Continuous bubbling in the water seal chamber should be reported to the provider as it can indicate an air leak. This finding suggests that air is escaping from the pleural space, which can lead to lung collapse or pneumothorax. Drainage of 75 mL in the past 24 hours is within the expected range for a client with a chest tube and is not a cause for concern. Intermittent bubbling in the water seal chamber is a normal finding that indicates the system is functioning properly. Tidaling in the water seal chamber is also an expected finding that shows the fluctuation of fluid with the client's breathing and is not alarming.
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A client is receiving discharge teaching about a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with milk.
- B. I should expect my stools to turn black.
- C. I should avoid eating oranges while taking this medication.
- D. I will take this medication on an empty stomach.
Correct Answer: B
Rationale: The correct answer is B. When taking ferrous sulfate, clients should expect their stools to turn black, which is a normal side effect due to the iron content. Choice A is incorrect because ferrous sulfate should not be taken with milk as it can decrease its absorption. Choice C is incorrect because vitamin C-rich foods like oranges can actually enhance the absorption of iron. Choice D is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption.
A client taking haloperidol is exhibiting extrapyramidal symptoms. Which intervention should the nurse anticipate?
- A. Increase the dose of haloperidol.
- B. Administer benztropine.
- C. Administer naloxone.
- D. Monitor blood pressure before administering the next dose.
Correct Answer: B
Rationale: The correct intervention for a client exhibiting extrapyramidal symptoms while taking haloperidol is to administer benztropine. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal symptoms caused by antipsychotic medications like haloperidol. Increasing the dose of haloperidol (Choice A) would exacerbate the symptoms rather than alleviate them. Administering naloxone (Choice C) is not indicated for extrapyramidal symptoms. Monitoring blood pressure (Choice D) is important but not the primary intervention for managing extrapyramidal symptoms.
A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?
- A. Ammonia 75 mcg/dL
- B. Sodium 142 mEq/L
- C. Calcium 9.5 mg/dL
- D. Bilirubin 2.5 mg/dL
Correct Answer: D
Rationale: An elevated bilirubin level in clients with cirrhosis indicates worsening liver function and potential complications. It is crucial to report this finding promptly as it may require immediate medical intervention. Elevated ammonia levels (choice A) are also concerning in cirrhosis, indicating hepatic encephalopathy, but bilirubin levels are more specific to liver function in this context. Choices B and C are within normal ranges and are not typically of immediate concern in cirrhosis.
A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?
- A. Request an interpreter of a different sex from the client
- B. Request a family member or friend to interpret information for the client
- C. Direct attention toward the interpreter when speaking to the client
- D. Review the facility policy about the use of an interpreter
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client who speaks a different language is to review the facility policy about the use of an interpreter. This ensures compliance with best practices for communication when using interpreters, maintaining accuracy and confidentiality. Requesting an interpreter of a different sex from the client (Choice A) is not relevant to effective communication. Asking a family member or friend to interpret (Choice B) can lead to misinterpretation or breach of confidentiality. Directing attention toward the interpreter (Choice C) is not as crucial as understanding the facility's policy on interpreter use.
A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following actions should the nurse take?
- A. Give the medication as a bolus over 10 minutes.
- B. Dilute the medication before administration.
- C. Infuse the medication at a rate of 10 mEq/hr.
- D. Administer the medication undiluted.
Correct Answer: C
Rationale: The correct action the nurse should take when administering potassium chloride IV to a client with hypokalemia is to infuse the medication at a rate of 10 mEq/hr. This slow infusion rate is crucial to prevent the development of hyperkalemia, a potentially dangerous condition. Option A is incorrect because giving the medication as a bolus over 10 minutes can lead to adverse effects. Option B is incorrect as potassium chloride does not necessarily need to be diluted before administration in this scenario. Option D is incorrect as administering the medication undiluted can also increase the risk of hyperkalemia.