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After a chest tube has been inserted to treat the client's pneumothorax, which finding indicates that the chest tube is functioning correctly?
- A. The water in the suction control chamber is bubbling.
- B. The water seal chamber has continuous vigorous bubbling.
- C. The drainage system is positioned upright.
- D. The client reports relief of chest pain.
Correct Answer: D
Rationale: Relief of chest pain indicates the chest tube is effectively re-expanding the lung and resolving the pneumothorax.
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During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
- A. Release the suction by opening the vent
- B. Continue suctioning to remove the obstruction
- C. Increase the pressure
- D. Suction deeper
Correct Answer: A
Rationale: Releasing suction by opening the vent prevents trauma to the tracheal mucosa when the catheter adheres to the wall.
Other than obtaining a vaccination against influenza, which nursing advice is most helpful to high-risk clients who want to avoid getting influenza?
- A. Consume adequate vitamin C.
- B. Avoid crowded places.
- C. Dress warmly in cold weather.
- D. Reduce daily stress and anxiety.
Correct Answer: B
Rationale: Avoiding crowded places reduces exposure to influenza, a highly contagious respiratory virus.
Which side effect can the nurse expect when the client receives aminophylline (Truphylline)?
- A. Bronchospasm
- B. Hypotension
- C. Drowsiness
- D. Tachycardia
Correct Answer: D
Rationale: Aminophylline, a xanthine derivative, commonly causes tachycardia as a side effect due to its stimulatory effects.
Which statement by the client indicates an accurate understanding of the purpose of aerosol therapy?
- A. Aerosol therapy relieves tissue irritation.
- B. Aerosol therapy delivers medication directly to the lungs.
- C. Aerosolization dries respiratory passages.
- D. Aerosol therapy helps to slow breathing.
Correct Answer: B
Rationale: Aerosol therapy delivers medication directly to the lungs, targeting the respiratory tract for effective treatment of bronchitis.
The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine?
- A. Elderly and chronically ill clients.
- B. Child-care workers and children less than four (4) years of age.
- C. Hospital chaplains and health-care workers.
- D. Schoolteachers and students living in a dormitory.
Correct Answer: A
Rationale: Elderly and chronically ill (A) are at highest risk for flu complications, prioritizing them. Child-care workers/children (B), chaplains/HCWs (C), and teachers/students (D) are secondary.