Nokea
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
- A. Order a chest x-ray
- B. Reinsert the tube
- C. Cover the insertion site with a Vaseline gauze
- D. Call the doctor
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air entry into the pleural space, stabilizing the client until further intervention.
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The nurse is caring for a client who is 12 weeks pregnant and presented with the following symptoms: mild uterine cramping with spotting of blood. The cervical os is closed upon examination. How should the nurse chart the findings?
- A. missed miscarriage
- B. complete miscarriage
- C. inevitable miscarriage
- D. threatened miscarriage
Correct Answer: D
Rationale: Mild cramping, spotting, and a closed cervical os at 12 weeks indicate a threatened miscarriage, where the pregnancy may still continue.
Which type of behavior modification is most likely to benefit a client who has a severe phobia regarding spiders?
- A. Positive reinforcement
- B. Negative reinforcement
- C. Desensitization
- D. Aversion therapy
Correct Answer: C
Rationale: Desensitization (C), gradually exposing the client to spiders, is most effective for phobias. Other methods (A, B, D) are less specific.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content
- B. Place the patient in a left-lying position
- C. Administer feeding with 50% Dextrose
- D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Correct Answer: A
Rationale: Aspirating stomach content confirms nasogastric tube placement, preventing aspiration.
What is the responsibility of the nurse in obtaining an informed consent for surgery?
- A. Describing in a clear and simply stated manner what the surgery will involve
- B. Explaining the benefits, alternatives, and possible risks and complications of surgery
- C. Using the nurse/client relationship to persuade the client to sign the operative permit
- D. Providing the informed consent for surgery and witnessing the client's signature
Correct Answer: D
Rationale: The nurse's role is to witness the client's signature and ensure the consent form is completed, not to explain the procedure.
A child with a history of seizures begins to seize suddenly in his hospital room. The nurse would do all of the following interventions EXCEPT
- A. loosen the child's clothing and remove the pillow from his bed.
- B. administer lorazepam rectally.
- C. roll the child on his side.
- D. restrain the child's arms and legs.
Correct Answer: D
Rationale: Restraining during a seizure risks injury. Loosening clothing, removing pillows, rolling to the side, and administering lorazepam (if ordered) are appropriate to ensure safety and stop the seizure.