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.
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Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
- A. Position the head of the client's bed flat
- B. Turn the client every 4 hours
- C. Brush the client's teeth with a suction toothbrush every 12 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: C
Rationale: The correct answer is C: Brush the client's teeth with a suction toothbrush every 12 hours. This is crucial in reducing the risk of ventilator-associated pneumonia as it helps prevent the buildup of bacteria in the oral cavity, which can be aspirated into the lungs. Brushing the teeth regularly maintains oral hygiene, decreasing the chances of infection.
A: Positioning the head of the client's bed flat can increase the risk of aspiration and pneumonia.
B: Turning the client every 4 hours is important for preventing pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia.
D: Providing humidity within the ventilator tubing is important for preventing mucous plugs but does not directly address oral hygiene, which is key in preventing pneumonia.
Mary asks how the pulmonary function test ordered by her physician is performed. You respond by saying
- A. You breathe into a spirometer to measure your lung capacity.
- B. You breathe through a mouthpiece into a spirometer until all air in your lungs is expelled; then you take a deep breath through the mouthpiece. This is done three times and a computer calculates the capacity of your lungs.
- C. A computer is used to measure your volume and vital capacity.
- D. A tube is inserted into your lungs while you are asleep to expand your lungs to their full capacity.
Correct Answer: B
Rationale: Pulmonary function tests measure lung capacity using spirometry.
Mr. Jones is being discharged today. Which of the following statements by Mr. Jones would indicate that he understands his postoperative regimen?
- A. I'm taking my nephew to the amusement park next week and we are going to ride the roller-coasters.'
- B. My brother will be coming over every day to help me with my bath and to shave me.'
- C. I think I'll watch the baseball games on TV this week rather than driving to the stadium.'
- D. I guess I'll have to take an early retirement since my job as an accountant requires me to use my eyes a lot.'
Correct Answer: C
Rationale: Avoiding strenuous activities like driving or riding roller coasters demonstrates understanding of activity restrictions necessary during recovery from retinal surgery.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.
Patients with a paralytic ileus typically have
- A. Intravenous fluid replacement and a nasogastric tube connected to suction.
- B. Surgical correction of the problem.
- C. Endoscopic injection of botulinum toxin or esophageal dilation.
- D. Endoscopy to allow biopsy followed with broad-spectrum antibiotics.
Correct Answer: A
Rationale: Paralytic ileus requires decompression of the gastrointestinal tract.