Nokea
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
- A. Continue to monitor the client.
- B. Notify the healthcare provider immediately.
- C. Increase the suction level.
- D. Reposition the client.
Correct Answer: A
Rationale: The correct answer is A. The rise in the water seal chamber with client inspiration indicates that the chest tube system is functioning properly. This rise is expected as the negative pressure in the pleural space increases during inspiration, causing the water level to momentarily increase. It is important for the nurse to understand this physiological response and continue to monitor the client for any signs of respiratory distress. Notifying the healthcare provider immediately or increasing suction level is unnecessary and may disrupt the client's respiratory status. Repositioning the client is not indicated in this situation.
You may also like to solve these questions
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Thyroid hormones
- B. Antihypertensives
- C. Steroids
- D. Insulin
Correct Answer: C
Rationale: The correct answer is C: Steroids. Steroids, specifically glucocorticoids, are known to increase the risk of osteoporosis by decreasing bone formation and increasing bone resorption. Long-term use of steroids can lead to bone loss, making individuals more susceptible to fractures. Thyroid hormones (A) do not directly cause osteoporosis. Antihypertensives (B) and insulin (D) are not associated with increased risk of osteoporosis.
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?
- A. Increase calcium intake
- B. Avoid foods high in potassium
- C. Drink 3 L of fluid every day
- D. Limit vitamin C intake
Correct Answer: C
Rationale: The correct answer is C: Drink 3 L of fluid every day. Adequate fluid intake helps to dilute urine, reducing the concentration of calcium and oxalate, which are the main components of kidney stones. This instruction can help prevent the formation of new stones. Increasing calcium intake (Choice A) may actually be beneficial as it can bind with oxalate in the intestines, reducing its absorption and subsequent excretion in the urine. Avoiding foods high in potassium (Choice B) is not directly related to preventing calcium oxalate stones. Limiting vitamin C intake (Choice D) is not necessary unless the client is taking excessive amounts of vitamin C supplements, which can increase oxalate levels.
A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching?
- A. Postcoital bleeding may occur.
- B. A pelvic ultrasound is required for diagnosis.
- C. Cervical polyps usually resolve without treatment.
- D. Cervical polyps are rarely associated with cancer.
Correct Answer: A
Rationale: The correct answer is A: Postcoital bleeding may occur. This information is essential to include in teaching about cervical polyps because it is a common symptom associated with this condition. Cervical polyps are benign growths on the cervix that can cause bleeding, especially after intercourse. It is crucial for the client to be aware of this symptom to monitor for any abnormal bleeding and seek medical attention if necessary.
Option B is incorrect because a pelvic ultrasound is not always required for diagnosing cervical polyps; they can often be diagnosed through a pelvic exam. Option C is incorrect because not all cervical polyps resolve on their own and may require treatment if symptomatic. Option D is incorrect because while cervical polyps are usually benign, they can be associated with an increased risk of cervical cancer in some cases.
A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?
- A. Artificial lubrication can be used to treat vaginal itching and dryness.
- B. Avoid sexual activity for the first 6 months.
- C. Use a menstrual pad for vaginal bleeding.
- D. Use a diaphragm for contraception.
Correct Answer: A
Rationale: The correct answer is A: Artificial lubrication can be used to treat vaginal itching and dryness. The rationale for this is that after a total abdominal hysterectomy and bilateral salpingo-oophorectomy, there is a decrease in estrogen levels, leading to vaginal dryness and itching. Using artificial lubrication can help alleviate these symptoms and improve comfort.
Choice B is incorrect as there is no need to avoid sexual activity for 6 months unless specifically advised by the healthcare provider. Choice C is incorrect as there should not be vaginal bleeding after a total abdominal hysterectomy. Choice D is incorrect as using a diaphragm for contraception is not recommended after a hysterectomy.
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
- A. Decreased potassium level
- B. Increased sodium level
- C. Increased calcium level
- D. Decreased magnesium level
Correct Answer: A
Rationale: The correct answer is A: Decreased potassium level. Postoperative ileus can lead to gastrointestinal fluid losses, causing a decrease in potassium levels due to excessive drainage through the NG tube. Potassium is an important electrolyte for maintaining normal muscle function, including the heart. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias.
Incorrect choices:
B: Increased sodium level - Unlikely in this scenario as excessive drainage would lead to fluid and electrolyte loss.
C: Increased calcium level - Unrelated to postoperative ileus and NG tube drainage.
D: Decreased magnesium level - Possible but not as critical as monitoring potassium levels in this situation.