Nokea
The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment?
- A. Obtain an order for a STAT chest x-ray.
- B. Increase the amount of wall suction.
- C. Check the tubing for kinks or clots.
- D. Monitor the client's pulse oximeter reading.
Correct Answer: C
Rationale: No tidaling suggests obstruction; checking for kinks/clots (C) is the first step. CXR (A), suction increase (B), and SpO2 (D) follow if unresolved.
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Which priority intervention should the nurse implement for the client diagnosed with coal workers' pneumoconiosis?
- A. Monitor the client's intake and output.
- B. Assess for black-streaked sputum.
- C. Monitor the white blood cell count daily.
- D. Assess the client's activity level every shift.
Correct Answer: B
Rationale: Black-streaked sputum (B) is a hallmark of coal workers' pneumoconiosis due to coal dust deposition, making its assessment a priority to confirm disease impact. Intake/output (A) is non-specific. Daily WBC counts (C) are unnecessary unless infection is suspected. Activity level (D) is secondary to symptom assessment.
The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription?
- A. These pills will make me feel better fast and I can return to work.
- B. The antibiotics will help prevent me from developing a bacterial pneumonia.
- C. If I had gotten this prescription sooner, I could have prevented this illness.
- D. I need to take these pills until I feel better; then I can stop taking the rest.
Correct Answer: B
Rationale: Antibiotics for influenza (B) prevent secondary bacterial pneumonia, not treat the virus. Quick recovery (A), prevention (C), and stopping early (D) are incorrect.
Which explanation to the client by the nurse regarding the use of antibiotics is best?
- A. Antibiotics are ineffective in treating viral infections.
- B. Antibiotics are ineffective after cold symptoms develop.
- C. Antibiotics only prevent the spread of colds to others.
- D. Antibiotics are used only for immunosuppressed individuals.
Correct Answer: A
Rationale: Head colds are typically caused by viruses, and antibiotics are effective against bacterial infections, not viral ones.
When administering oxygen to the client through a partial rebreathing mask, which observation is most important for the nurse to report to the respiratory therapy department?
- A. Moisture is accumulating inside the mask.
- B. The bag collapses during inspiration.
- C. The mask covers the client's mouth and nose.
- D. The strap around the client's head is snug.
Correct Answer: B
Rationale: A collapsing bag during inspiration indicates inadequate oxygen flow, which must be reported to ensure proper oxygen delivery.
A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician?
- A. Patient reports a change in vision.
- B. Patient reports a metallic taste in the mouth.
- C. The patient has ringing in their ears.
- D. The patient has a persistent dry cough.
Correct Answer: C
Rationale: This medication can be very toxic to the ears (cranial nerve 8). Therefore, it is alarming if the patient reports ringing in their ears, which could represent ototoxicity.