Nokea
A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct Answer: A
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak.
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A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level.
A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?
- A. Notify the physician.
- B. Clamp the chest tube.
- C. Replace the system.
- D. Document the finding.
Correct Answer: D
Rationale: Gentle bubbling is a normal finding for the client who has a pleural drainage system to suction, so it simply needs to be documented. If the bubbling becomes vigorous, it could indicate a leak, which the nurse needs to investigate. The remaining choices are not necessary.
The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
- A. Place the client in the waiting room until an available cubicle is open
- B. Seclude the client from other clients and visitors
- C. Perform no intervention because it might not be necessary until tests confirm a disease
- D. Don gown, gloves, and mask immediately
Correct Answer: B
Rationale: Symptoms suggestive of tuberculosis require immediate seclusion to prevent transmission, with caregivers using respirator masks.
A 46 year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
- A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
- B. Allow the patient to begin limited ambulation with assistance.
- C. Recommend a physical therapy consultation for ambulation.
- D. Tell the patient to remain with leg straight for another 6 hours and check the chart for activity orders.
Correct Answer: A
Rationale: The patient should keep the leg straight for at least 4 hours.
Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:
- A. outbreak of Asian flu.
- B. Chemical exposure.
- C. bacterial pneumonia.
- D. allergic reaction.
Correct Answer: B
Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure.