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A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?
- A. Place the client in a supine position.
- B. Ensure the device is kept below the level of the client's chest.
- C. Empty the collection chamber every 8 hr.
- D. Clamp the chest tube every 4 hr.
Correct Answer: B
Rationale: Keeping the drainage system below chest level ensures proper drainage and prevents backflow. Supine positioning may hinder drainage, routine emptying isn't needed, and clamping can interfere with suction.
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A nurse is caring for a client who is postoperative following a knee arthroscopy. Which of the following actions should the nurse take?
- A. Apply a warm compress to the surgical site.
- B. Elevate the client's leg.
- C. Encourage the client to bear weight immediately.
- D. Administer a stool softener daily.
Correct Answer: B
Rationale: Elevating the leg reduces swelling and promotes recovery. Warm compresses risk inflammation, early weight-bearing may harm, and stool softeners aren't routine.
A nurse is reinforcing teaching with a client who has a new prescription for tramadol. Which of the following instructions should the nurse include?
- A. Take this medication with food to prevent nausea.
- B. You might experience constipation while taking this medication.
- C. You should avoid driving until you know how this medication affects you.
- D. You can increase the dose if your pain persists.
Correct Answer: B,C
Rationale: Tramadol can cause constipation, and its sedative effects warrant avoiding driving initially. Food may help nausea but isn't required, and dose increases need provider approval.
A nurse is reinforcing teaching about laboratory testing with a client. Which of the following findings should the nurse include as an indicator of infection?
- A. Decreased platelets
- B. Increased iron level
- C. Increased erythrocyte sedimentation rate
- D. Decreased hemoglobin
Correct Answer: C
Rationale: Increased ESR indicates inflammation, often due to infection. Platelet or hemoglobin decreases or iron increases aren't specific to infection.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse report to the provider?
- A. The client's oxygen saturation is 95%.
- B. The client's cuff pressure is 35 cm H2O.
- C. The client's respiratory rate is 16 breaths/min.
- D. The client's temperature is 37.1°C (98.8°F).
Correct Answer: B
Rationale: A cuff pressure of 35 cm H2O (above 20-30 cm H2O) risks tracheal damage, requiring reporting. Normal saturation, respiratory rate, and temperature are unremarkable.
A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience weight loss while taking this medication.
- C. You need to avoid tyramine-rich foods while taking this medication.
- D. You can expect symptom improvement within 24 hours.
Correct Answer: A
Rationale: Fluoxetine is often taken at bedtime to minimize daytime side effects like agitation. Weight changes vary, tyramine isn't a concern, and effects take weeks.