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Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
- A. Lift and clear drainage from the chest tube.
- B. Inspect the tube insertion site for leaking.
- C. Continue to monitor the drainage system.
- D. Auscultate lungs for unequal breath sounds.
Correct Answer: C
Rationale: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.
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History and physical
Flow sheet
Nurses’ Notes
Imaging studies 1935
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the patient’s husband noticed his wife’s speech became difficult to understand
Specify which findings indicate early interventions for an ischemic stroke were effective? Focused assessment area: Neurological, Muscoskeletal, Psychosocial
- A. Neurological: Drinks with repetitive cough, Speaks in short sentences, Decorticate posturing; Muscoskeletal: Flaccidity of left arm, Ambulates with a walker, Passive range of motion on left leg; Psychosocial: Fits of laughter, Tearful sharing of stories, Angry outburst
- B. Neurological: Speaks in short sentences; Muscoskeletal: Ambulates with a walker; Psychosocial: Tearful sharing of stories
Correct Answer: B,B,B
Rationale: Neurological: Speaking in short sentences indicates improved speech from garbled to intelligible. Muscoskeletal: Ambulating with a walker shows regained mobility. Psychosocial: Tearful sharing of stories reflects normal emotional expression and preserved memory, indicating effective early interventions.
A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
- A. Gastroccult positive emesis.
- B. Strong foul smelling flatus.
- C. Complaint of poor night vision.
- D. Loose bowel movements.
Correct Answer: A
Rationale: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?
- A. Perform a complete mental status exam.
- B. Determine if the client has had a shingles vaccination.
- C. Teach the client about phantom pain symptoms.
- D. Complete an assessment of the client's pain.
Correct Answer: D
Rationale: Completing a pain assessment is the most important action to identify the cause, severity, and impact of the pain, likely postherpetic neuralgia, to plan appropriate interventions.
History and Physical
Nurses notes
Orders
Flow Sheets
Laboratory Test
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ESRD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had a poor appetite and was not able to go for her scheduled dialysis.
The nurse is reviewing the physician orders for a 68-year-old client with end-stage renal disease (ESRD) presenting with fatigue, weakness, muscle cramps, tingling, and lightheadedness after missing dialysis. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.
- A. Basic metabolic panel
- B. Echocardiogram
- C. CT scan of abdomen
- D. Blood cultures times 2 sets
- E. Chest X-ray
- F. Placing the client on a continuous cardiac monito
- G. 12 lead EKG
Correct Answer: F,G
Rationale: Placing the client on a continuous cardiac monitor and performing a 12-lead EKG are priority orders due to the client's history of CAD, HTN, and symptoms suggestive of a possible myocardial infarction or arrhythmia.
The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?
- A. Hepatorenal failure.
- B. Acute pancreatitis.
- C. Surgical site infection.
- D. Biliary duct obstruction.
Correct Answer: B
Rationale: Acute pancreatitis is indicated by fever, upper abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels, likely triggered by the cholecystectomy.