Nokea
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?
- A. The client should be told to breathe normally.
- B. The client should be told to take two or three deep breaths as the drain is being removed.
- C. The client should be told to hold his breath as the drain is being removed.
- D. The client should breathe slowly as the drain is being removed.
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.
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The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Shortness of breath and crackles.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication. Options A, B, and D are normal.
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Continue to monitor the client to see if the bubbling increases
- D. Instruct the client to try to avoid coughing
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
- A. The client will need to take her medication with meals.
- B. The client will need to learn how to check the specific gravity of her urine.
- C. The client will need to modify her daily activities.
- D. The client will need to learn the proper method of drug administration.
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.
Which item should be kept at the bedside of a client who has just returned from having a thyroidectomy?
- A. A padded tongue
- B. An endotracheal tube
- C. An airway
- D. A tracheostomy set
Correct Answer: D
Rationale: A tracheostomy set is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy. Options A, B, and C are less critical in this context.
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection.
The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment is to
- A. minimize the bacterial count in the mouth.
- B. soften the mucous membranes of the tongue before surgery.
- C. stimulate the microcirculation of the mouth.
- D. hydrate the tissues of the gums.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the procedure. (1) correct-destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes