Nokea
An adult has a chest drainage system. The client's wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to:
- A. go get petrolatum gauze and apply over the wound.
- B. place her/his hand firmly over the wound.
- C. apply a sterile 4x4 dressing.
- D. reinsert the chest tube.
Correct Answer: B
Rationale: Placing a hand firmly over the wound prevents air from entering the pleural space, which could cause a pneumothorax.
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The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?
- A. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain.
- B. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
- C. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
- D. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Correct Answer: C
Rationale: Purulent drainage post-Caldwell-Luc (C) suggests infection, requiring experienced assessment. Antral irrigation (A), tonsillectomy refusal (B), and antibiotics (D) are less complex.
Which nursing rationale best explains the reason for using a cuffed tracheostomy tube on the client?
- A. The cuff prevents skin breakdown.
- B. The cuff prevents aspiration.
- C. The cuff is more comfortable.
- D. The cuff reduces infection.
Correct Answer: B
Rationale: The cuff on a tracheostomy tube seals the airway, preventing aspiration of secretions or food into the lungs.
The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?
- A. Vitamin C, 2,000 mg daily.
- B. Strict bedrest.
- C. Humidification of the air.
- D. Decongestant therapy.
Correct Answer: A
Rationale: Vitamin C (A) is an alternative therapy for colds, with unproven efficacy. Bedrest (B), humidification (C), and decongestants (D) are standard supportive measures.
Your patient's asthma is poorly controlled. The patient reports using their rescue inhaler 4 times a week. In addition, the patient's asthma is not responding to other treatments. The physician orders the patient to take a medication that works by blocking the role of the immunoglobulin IgE. This describes which medication below?
- A. Montelukast
- B. Omalizumab
- C. Cromolyn
- D. Salmeterol
Correct Answer: B
Rationale: Omalizumab is a monoclonal antibody that binds to IgE, preventing it from triggering allergic responses in asthma.
Which position is best for the client to be in while the nurse prepares to assess breath sounds?
- A. Sitting
- B. Standing
- C. Lying on the back
- D. Lying on the side
Correct Answer: A
Rationale: Sitting upright allows optimal lung expansion, making it easier to assess breath sounds accurately in a client with asthma.