Nokea
How should the nurse position Mr. Jones’ chest drainage unit while he is transported?
- A. Below the chest level
- B. On the stretcher
- C. The unit should be removed
- D. The tubes should be clamped
Correct Answer: A
Rationale: The correct answer is A: Below the chest level. Positioning the chest drainage unit below the chest level allows for effective drainage of air or fluid from the chest cavity. Placing it above the chest level may cause backflow or air/fluid accumulation. Option B is incorrect as the unit should be secured to prevent dislodging during transport. Option C is incorrect as removing the unit can lead to complications. Option D is incorrect as clamping the tubes can result in a tension pneumothorax. Positioning the unit below the chest level ensures proper drainage and prevents complications during transport.
You may also like to solve these questions
Describe the relationship between receptors and neurotransmitters.
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
What symptoms would a nurse suspect in a client with acoustic neuroma?
- A. Altered facial sensation
- B. Vertigo only when standing
- C. Tinnitus in the unaffected ear
- D. Impaired facial movement when smiling
Correct Answer: A
Rationale: Acoustic neuromas often affect cranial nerve VII, leading to altered facial sensation.
What nursing measure assumes priority for Mr. Johnson with sudden diarrhea and high fever?
- A. Determine if he had been working on an air-conditioning unit of a high-rise building
- B. Place the patient in isolation
- C. Monitor respiratory status carefully and observe for signs of hypoxia
- D. Begin discharge teaching
Correct Answer: C
Rationale: The correct answer is C, to monitor respiratory status and observe for signs of hypoxia. This is because sudden diarrhea and high fever can indicate a potential infectious illness, which can lead to respiratory complications such as pneumonia. Monitoring respiratory status is crucial to detect any signs of respiratory distress or hypoxia early on.
A: Determining his work on an air-conditioning unit is not a priority at this time as it does not directly address his immediate health concerns.
B: Placing the patient in isolation may be necessary later depending on the diagnosis, but it is not the priority at this moment.
D: Beginning discharge teaching is not appropriate as the patient is currently experiencing acute symptoms that require immediate attention.
In summary, monitoring respiratory status is the priority to ensure early detection and intervention for any potential respiratory complications in a patient with sudden diarrhea and high fever.
To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to
- A. avoid crowds and obtain an annual influenza vaccination.
- B. drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
- C. eat a potassium-rich, low-sodium diet.
- D. practice good dental hygiene and report gum swelling or bleeding.
Correct Answer: D
Rationale: Phenytoin can cause gum hyperplasia, so good dental hygiene is essential.
9. When the family members of a postoperative patient leave after a visit, the patient tells the nurse that his family gave him a headache by fussing over him so much. What is an appropriate intervention by the nurse?
- A. Administer the PRN analgesic prescribed for his postoperative pain.
- B. Ask the patient’s permission to use acupressure to ease his headache.
- C. Reassure the patient that his headache will subside now that his family has gone.
- D. Teach the patient biofeedback methods to relieve his headaches by controlling cerebral blood flow.
Correct Answer: B
Rationale: Asking the patient’s permission to use acupressure (option B) is an appropriate non-pharmacological intervention that respects patient autonomy and may effectively alleviate the headache.