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A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
- A. Reposition the client
- B. Check the chest tube for kinks
- C. Increase the suction pressure
- D. Administer pain medication
Correct Answer: A
Rationale: Repositioning the client can help alleviate chest burning caused by the chest tube.
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A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Use purified water for drinking.
- C. Limit intake of fried foods.
- D. Get vaccinated for hepatitis C.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods prepared with tap water. Tap water in certain regions may be contaminated with hepatitis-causing viruses. Using bottled or purified water for drinking alone (choice B) may not prevent exposure through food preparation. Limiting fried foods (choice C) is unrelated to preventing viral hepatitis. While getting vaccinated for hepatitis C (choice D) is important, it is not directly related to preventing exposure through contaminated tap water. Therefore, the most effective preventive measure is to avoid foods prepared with tap water to reduce the risk of acquiring viral hepatitis.
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. Estrogen therapy will reverse vaginal dryness.
- C. Do not use tampons for 6 months.
- D. Avoid sexual activity for 1 year.
Correct Answer: A
Rationale: Correct Answer: A. Artificial lubrication can be used to treat vaginal itching and dryness.
Rationale: After a total abdominal hysterectomy and bilateral salpingo-oophorectomy, the client will experience menopausal symptoms due to the removal of the ovaries. Vaginal dryness and itching are common symptoms that can be managed with artificial lubrication. Estrogen therapy is contraindicated in this client due to the history of uterine cancer. Using tampons can increase the risk of infection post-surgery. Avoiding sexual activity for 1 year is not necessary unless advised by the healthcare provider.
A nurse in an ophthalmology clinic assesses a client suspected of having cataracts. What is an expected symptom?
- A. Eye pain
- B. Sudden vision loss
- C. Decreased ability to perceive colors
- D. Excessive tearing
Correct Answer: C
Rationale: The correct answer is C: Decreased ability to perceive colors. Cataracts cause clouding of the eye's lens, leading to a decrease in the perception of colors. Eye pain (A) is not a typical symptom of cataracts. Sudden vision loss (B) is more commonly associated with conditions like retinal detachment. Excessive tearing (D) is not a prominent symptom of cataracts. Make sure to assess for other symptoms like blurred vision, sensitivity to light, and difficulty seeing at night.
A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. This can lead to hypokalemia, which can be dangerous in a client with heart failure as it can worsen cardiac function and lead to arrhythmias. The nurse should monitor the client's potassium levels regularly to prevent this adverse effect.
Summary of other choices:
B: Hyperkalemia - Furosemide does not typically cause hyperkalemia.
C: Hypernatremia - Furosemide is a diuretic that can lead to sodium loss, not hypernatremia.
D: Hypertension - Furosemide is actually used to treat hypertension, so it is not an adverse effect of the medication in this scenario.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.