Nokea
John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
Appropriate patient teaching when the chest tube is removed:
- A. Instruct the patient take deep breath and hold it during removal.
- B. Inform the patient that this is not a painful procedure.
- C. Ensure that the site is covered with a loose, dry dressing.
- D. Expect tachypnea after the removal.
Correct Answer: A
Rationale: Holding a deep breath during removal prevents air entry into the pleural space.
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The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply:
- A. Wear gloves when handling tissues containing sputum
- B. Wear a face mask at all times
- C. Keep the client in strict isolation
- D. When the client leaves the room for tests, have all people in contact with him wear a mask
- E. Keep the client's door open to allow fresh air into room and prevent social isolation
- F. Wash hands after direct contact with the client or contaminated articles
Correct Answer: A,B,F
Rationale: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his room; masks must be discarded before leaving the client's room. Hand washing is required after direct contact with the client or contaminated articles. Strict isolation isn't required if the client adheres to special respiratory precautions. The client, not the people in contact with him, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.
John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
The level of the water in the water-seal chamber is at
- A. 2 cm
- B. -20 cm
- C. -10 cm
- D. -80 cm
Correct Answer: A
Rationale: The water-seal chamber is maintained at 2 cm to prevent air entry.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine (prochlorperazine) is incompatible with most medications, including Stadol (butorphanol), in the same syringe, as mixing may cause precipitation or reduced efficacy. Drawing them in separate syringes ensures safe administration. Monitoring vital signs (A) is less critical, dilution (B) is inappropriate, and verifying the route (D) is unnecessary as IM is specified.
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
- A. Administration of cough suppressants
- B. Increasing oral fluid intake to 3000 cc per day
- C. Maintaining bed rest with bathroom privileges
- D. Performing chest physiotherapy twice a day
Correct Answer: B
Rationale: Increasing oral fluid intake to 3000 cc per day. Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions.
The nurse is caring for a preschooler who needs stitches resulting from an injury received during play in the yard. What would be the most appropriate way to prepare the child for the treatment he will receive?
- A. Tell the child the nurse and the doctor will 'make things all better.'
- B. Use dolls and explain through play and simulation what will be done.
- C. Explain to the child slowly and precisely the steps that will be taken in his treatment.
- D. Tell the child that he will have minimal scarring and that any marks will diminish over time.
Correct Answer: B
Rationale: Play-based explanation with dolls engages a preschooler's developmental level, effectively preparing them for stitches.