Nokea
In caring for a patient with neutropenia, what tasks can be delegated to the nursing assistant? (Choose all that apply.)
- A. Take vital signs every 4 hours.
- B. Report temperature elevation >100.4° F.
- C. Assess for sore throat,cough or burning with urination.
- D. Gather the supplies to prepare the room for protective isolation.
Correct Answer: B
Rationale: Tasks such as taking vital signs, reporting fever, and preparing the room for isolation are within the scope of a nursing assistant, while assessing for specific symptoms requires more advanced clinical skills.
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During the rehabilitation of a patient with limited mobility, how can decubitus ulcers be prevented?
- A. Turning the patient every 4 hours
- B. Using a heat lamp on reddened areas
- C. Applying vitamin C to bony prominences
- D. Keeping the skin clean, dry, and well lubricated
Correct Answer: D
Rationale: Maintaining skin integrity through cleanliness and moisture management prevents pressure ulcers.
After administering injections of penicillin, the nurse should ask the client to wait at least __ minutes before allowing the client to leave the healthcare facility.
- A. 12
- B. 15
- C. 5
- D. 30
Correct Answer: B
Rationale: The rationale is that waiting 15 minutes allows time to observe for any adverse reactions to the medication.
A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?
- A. Arterial blood gases
- B. Urinary output
- C. Chest tube drainage
- D. Pain level
Correct Answer: A
Rationale: The correct answer is A: Arterial blood gases. This is the highest priority assessment for a client post-thoracotomy and lobectomy as it helps monitor the client's oxygenation status and acid-base balance, crucial after thoracic surgery. ABGs provide immediate information on the client's respiratory function, detecting any respiratory complications early on. The other options, B: Urinary output, C: Chest tube drainage, and D: Pain level, are important assessments but not as critical as monitoring the client's oxygenation status post-thoracic surgery. Urinary output is important for renal function, chest tube drainage for monitoring for any bleeding or air leakage, and pain level for comfort, but none of these directly assess the client's respiratory status and potential complications.
The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A
Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.
Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.
Which statements are correct for lithium?
- A. Effective for all
- B. Has a delay of 10 to 28 days in achieving therapeutic benefits
- C. Has a narrow range of safety between a therapeutic serum level and toxic levels
- D. May be therapeutic when administered in combination with any other drugs
Correct Answer: C
Rationale: Lithium has a narrow therapeutic window, requiring careful monitoring to prevent toxicity.