Nokea
Mary has been dieting and exercising daily. Her weight is well below the recommended minimum for her height. Assessment for Mary would include looking for
- A. Ecchymosis and extraocular movements.
- B. Temporal wasting and irregular heart rhythm.
- C. Peripheral edema and rales.
- D. Periorbital edema and chorea.
Correct Answer: B
Rationale: Extreme weight loss can lead to temporal wasting and cardiac irregularities.
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A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?
- A. Clamp the tube when the client is ambulating.
- B. Keep the collection device below the level of the client's chest.
- C. Carefully coil the tubes to prevent kinking.
- D. Position the client flat to avoid leaks in the tubing.
Correct Answer: B
Rationale: The correct answer is B: Keep the collection device below the level of the client's chest. This is important to ensure proper drainage and prevent backflow or air from entering the pleural space. Placing the collection device below the chest allows gravity to assist in drainage. Clamping the tube while ambulating (choice A) can lead to increased pressure in the chest, risking complications. Coiling the tubes (choice C) may cause kinks, obstructing drainage. Positioning the client flat (choice D) can lead to leaks in the tubing due to elevated pressure.
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Oxygen saturation of 95%
- B. No fluctuations in the water seal chamber
- C. No reports of pleuritic chest pain
- D. Occasional bubbling in the water-seal chamber
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.
What nursing action is most appropriate if Mr. Puff is lying flat in bed with shallow respirations and cyanosis?
- A. Change his nasal cannula to a Venturi mask
- B. Offer him water to increase his fluid intake
- C. Offer to walk him in the hall to increase his mobility
- D. Sit him up in bed with arms resting on pillows on the overbed table
Correct Answer: D
Rationale: Upright positioning enhances diaphragmatic movement and oxygenation.
A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis. In this case, the low pH indicates acidosis, and the elevated PaCO2 indicates respiratory involvement. In respiratory acidosis, the lungs cannot eliminate enough CO2, leading to an increase in carbonic acid and a decrease in pH. Metabolic acidosis (choice A) would involve a primary decrease in bicarbonate levels, not seen in this scenario. Metabolic alkalosis (choice B) would involve an increase in bicarbonate levels, which is not indicated by the given information. Respiratory alkalosis (choice D) would have a low PaCO2 and an elevated pH, opposite of what is seen here.
What is the role of corticosteroids in treating uveitis?
- A. Reduce inflammation
- B. Prevent infection
- C. Correct refractive errors
- D. None of the above
Correct Answer: A
Rationale: Corticosteroids are used to reduce inflammation in uveitis, preserving vision.