Nokea
A primary health care provider is inserting a chest tube. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site?
- A. Petrolatum jelly gauze
- B. Sterile 4 x 4 gauze pad
- C. Absorbent gauze dressing
- D. Gauze impregnated with povidone-iodine
Correct Answer: A
Rationale: The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. The items in the remaining options would not be selected as the first protective layer.
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A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
A client has just been admitted to the emergency department with chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis?
- A. Stable angina
- B. Unstable angina
- C. Prinzmetal's angina
- D. New-onset myocardial infarction (MI)
Correct Answer: D
Rationale: Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise 3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Troponin I is particularly sensitive to myocardial muscle injury; therefore, the client's results are compatible with new-onset MI. Options 1, 2, and 3 all refer to angina. These levels would not be elevated in angina.
A client admitted to the nursing unit with a closed head injury 6 hours ago has begun to vomit, and reports being dizzy and having a headache. Based on these data, which is the most important nursing action?
- A. Administering a prescribed antiemetic
- B. Notifying the primary health care provider of the client's condition
- C. Having the client rate the headache pain on a scale of 1 to 10
- D. Reminding the client to use the call bell when needing help to the bathroom
Correct Answer: B
Rationale: The client with a closed head injury is at risk of developing increased intracranial pressure (ICP). Increased ICP is evidenced by signs and symptoms such as headache, dizziness, confusion, weakness, and vomiting. Because of the implications of the client's manifestations, the most important nursing action is to notify the primary health care provider. Although the other nursing actions are not inappropriate, none of them address the critical issue of the potential of the client developing ICP.
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection?
- A. Dependent edema
- B. Diminished distal pulse
- C. Coolness and pallor of the skin
- D. Presence of warm areas on the cast
Correct Answer: D
Rationale: Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.
The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
- A. Dorsal aspect of the upper arm near a mole
- B. Inner aspect of the forearm that is close to a burn scar
- C. Inner aspect of the forearm that is not heavily pigmented
- D. Dorsal aspect of the upper arm that has a small amount of hair
Correct Answer: C
Rationale: Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.