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.
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A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Chest pain
- B. Hypotension
- C. Generalized urticaria
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (A) is more indicative of a possible cardiac issue. Hypotension (B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.
A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment?
- A. Hair loss
- B. Nausea and vomiting
- C. Fatigue
- D. Skin irritation
Correct Answer: C
Rationale: The correct answer is C: Fatigue. Radiation treatment can cause fatigue as it affects healthy cells in addition to cancer cells, leading to increased tiredness. Hair loss (A) is more commonly associated with chemotherapy, while nausea and vomiting (B) are typical side effects of chemotherapy or certain medications. Skin irritation (D) is a common side effect of radiation treatment, but fatigue is the primary adverse effect in this scenario due to its impact on overall energy levels.
A nurse is teaching a client with a history of calcium oxalate kidney stones. What advice should be given?
- A. Limit fluid intake to 1 L per day.
- B. Drink 3 L of fluid every day.
- C. Increase calcium intake.
- D. Avoid all citrus juices.
Correct Answer: B
Rationale: The correct answer is B: Drink 3 L of fluid every day. Increasing fluid intake helps prevent the formation of kidney stones by diluting the urine and reducing the concentration of minerals like calcium oxalate. Adequate hydration promotes frequent urination, which helps flush out these minerals. Limiting fluid intake (choice A) can lead to concentrated urine and increase the risk of stone formation. Increasing calcium intake (choice C) can actually help prevent calcium oxalate stones, as calcium binds with oxalate in the intestines, reducing its absorption. Avoiding all citrus juices (choice D) is unnecessary, as they do not directly contribute to the formation of calcium oxalate stones.
A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching?
- A. I should avoid heavy lifting.
- B. Feces can be present in the vagina.
- C. I might experience urinary incontinence.
- D. Pelvic pressure may occur during intercourse.
Correct Answer: B
Rationale: The correct answer is B. Feces present in the vagina is not a manifestation of uterine prolapse; it is a symptom of rectocele. The other choices are correct for uterine prolapse: A - Heavy lifting can worsen prolapse, C - Urinary incontinence is common due to pelvic floor weakness, D - Pelvic pressure during intercourse is a symptom. Therefore, the client mentioning feces in the vagina indicates a need for further teaching on distinguishing between uterine prolapse and rectocele symptoms.
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. Aspirin therapy
- B. Calcium supplements
- C. Estrogen therapy
- D. Thyroid hormones
Correct Answer: D
Rationale: The correct answer is D: Thyroid hormones. Excessive use of thyroid hormones can lead to osteoporosis by increasing bone turnover and reducing bone mineral density. Thyroid hormones can interfere with the normal process of bone formation and resorption, leading to weakened bones. Aspirin therapy (A) is not a risk factor for osteoporosis. Calcium supplements (B) are actually recommended to prevent osteoporosis. Estrogen therapy (C) is also not a risk factor; in fact, estrogen helps to maintain bone density.