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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If the client is typical of most others diagnosed with lung cancer, which early-warning sign was most likely ignored?
- A. Difficulty swallowing
- B. Gradual weight loss
- C. Persistent cough
- D. Coughing up blood
Correct Answer: C
Rationale: A persistent cough is a common early symptom of lung cancer that is often ignored, delaying diagnosis.
The nurse instructs the client's spouse to empty and thoroughly clean the vaporizer after each use. Which rationale provides the basis for the nurse's instruction?
- A. There is a potential for injury if the vaporizer is accidentally knocked off a nightstand.
- B. When the vaporizer is not cleaned, there is the growth of environmental pathogens.
- C. The vaporizer can collect dust, which could affect the client's breathing.
- D. Water evaporation causes calcium deposits that will obstruct the vaporizer.
Correct Answer: B
Rationale: A cool-mist vaporizer can harbor pathogens like bacteria and mold if not cleaned properly, potentially worsening respiratory symptoms.
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.
You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education?
- A. Cough for a minimum of 6 weeks
- B. Night sweats
- C. Weight gain
- D. Hemoptysis
- E. Chills
- F. Fever
- G. Chest pain
Correct Answer: B,D,E,F,G
Rationale: Tuberculosis symptoms include night sweats , hemoptysis , chills , fever , and chest pain (G). A cough typically lasts 3 weeks or more, not necessarily 6 weeks (not A). Weight loss, not weight gain , is common.
Which nursing assessment is most important when caring for a client experiencing a severe allergic reaction?
- A. Taking the client's temperature
- B. Assessing the client's blood pressure
- C. Monitoring the client's respiratory status
- D. Checking the client's pupillary response
Correct Answer: C
Rationale: Monitoring respiratory status is critical during a severe allergic reaction, as anaphylaxis can cause airway obstruction and respiratory distress.