Nokea
A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?
- A. Clamp the chest tube
- B. Maintain the drainage below the level of the chest
- C. Elevate the chest tube above chest level
- D. Avoid frequent dressing changes
Correct Answer: B
Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.
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What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?
- A. Fluid restrictions are not needed for all clients with chronic kidney disease.
- B. You may need to limit fluid intake to prevent fluid overload.
- C. Fluid restrictions are based on your lab results and daily weights.
- D. Restricting fluids is only necessary during dialysis.
Correct Answer: B
Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.
A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?
- A. Hyperactivity
- B. Hypervigilance
- C. Restlessness
- D. Avoidance of social situations
Correct Answer: B
Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.
What are the signs and symptoms of opioid withdrawal, and how should they be managed?
- A. Nausea, sweating, and increased heart rate; manage with methadone
- B. Pain and restlessness; manage with naloxone
- C. Hallucinations and muscle cramps; manage with clonidine
- D. Severe vomiting and seizures; manage with benzodiazepines
Correct Answer: A
Rationale: The signs and symptoms of opioid withdrawal include nausea, sweating, and increased heart rate. Methadone is commonly used to manage opioid withdrawal symptoms by alleviating them. Choice B, managing with naloxone, is incorrect as naloxone is primarily used for opioid overdose reversal, not withdrawal. Choice C, managing with clonidine, is incorrect as clonidine is used to manage some symptoms of withdrawal, such as anxiety, agitation, and hypertension, but not hallucinations. Choice D, managing with benzodiazepines, is incorrect as benzodiazepines are not typically used as first-line treatment for opioid withdrawal; they may be considered in specific cases but are not a standard approach.
A nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?
- A. Increased admissions
- B. 12% fewer urinary tract infections
- C. Increased mortality rate
- D. No changes in staffing
Correct Answer: B
Rationale: The correct answer is B: '12% fewer urinary tract infections.' Tracking infections, such as UTIs, is crucial in assessing care quality improvements as the reduction in infections indicates better infection control practices and overall quality of care. Choices A, C, and D are incorrect. Increased admissions (Choice A) do not directly reflect improvements in care quality. Increased mortality rate (Choice C) is a negative outcome and demonstrates a decline in care quality. No changes in staffing (Choice D) do not provide direct evidence of care quality improvements.
What are the key signs of hyperkalemia and how should it be treated?
- A. Elevated potassium levels, muscle weakness; administer calcium gluconate
- B. Decreased potassium levels, confusion; administer potassium chloride
- C. Elevated sodium levels, bradycardia; administer sodium bicarbonate
- D. Low sodium levels, muscle cramps; administer sodium chloride
Correct Answer: A
Rationale: The correct signs of hyperkalemia include elevated potassium levels and muscle weakness. The treatment involves administering calcium gluconate to help stabilize the heart. Choice B is incorrect as hyperkalemia is characterized by elevated, not decreased, potassium levels. Choice C is incorrect as hyperkalemia does not involve elevated sodium levels, and the treatment is not sodium bicarbonate. Choice D is incorrect as hyperkalemia does not lead to low sodium levels, and sodium chloride is not the treatment for hyperkalemia.