Nokea
The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take a deep breath
- D. Sneeze on command
Correct Answer: B
Rationale: Holding breath and bearing down (Valsalva maneuver) prevents air entry into the pleural space during chest tube removal.
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A client has had diarrhea for the past 3 days. Which acid/base imbalance would the nurse expect the client to have?
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Prolonged diarrhea leads to loss of bicarbonate, causing metabolic acidosis.
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
- A. Weight gain
- B. Hair loss
- C. Sore throat
- D. Brittle nails
Correct Answer: C
Rationale: Pulmozyme, used to thin mucus in cystic fibrosis, can cause sore throat as a side effect due to irritation from inhalation.
The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?
- A. A client 2 days post-appendectomy
- B. A client 1 week post-thyroidectomy
- C. A client 3 days post-splenectomy
- D. A client 2 days post-thoracotomy
Correct Answer: D
Rationale: A post-thoracotomy patient requires RN monitoring for respiratory complications.
A pediatric nurse would be concerned by which of the following sets of vital signs?
- A. newborn: BP 70/50, RR 47, HR 135
- B. 12-month-old: BP 65/55, RR 50, HR 130
- C. 10-year-old: BP 110/70, RR 16, HR 89
- D. 13-year-old: BP 120/82, RR 15, HR 80
Correct Answer: B
Rationale: 12-month-old vitals (BP 65/55, RR 50, HR 130) show low BP (normal ~90/50) and high RR (normal 20-30), suggesting distress. Other options are age-appropriate.
While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
- A. Place the implant in a biohazard bag and return it to the lab
- B. Give the client a pair of gloves and ask her to reinsert the implant
- C. Use tongs to pick up the implant and return it to a lead-lined container
- D. Discard the implant in the commode and double-flush
Correct Answer: C
Rationale: Radioactive implants must be handled with tongs and placed in a lead-lined container to minimize radiation exposure, per safety protocols.