Nokea
The healthcare provider is assessing a client who has a chest tube in place following a pneumothorax. Which finding should be reported to the healthcare provider immediately?
- A. Bubbling in the water seal chamber
- B. Drainage greater than 70 ml/hour
- C. Tidaling in the water seal chamber
- D. Absence of breath sounds on the affected side
Correct Answer: D
Rationale: The absence of breath sounds on the affected side is a critical finding that may indicate a tension pneumothorax, a life-threatening condition requiring immediate intervention. This situation can lead to a shift of the mediastinum and impaired ventilation. Bubbling in the water seal chamber is an expected finding in a chest tube drainage system and indicates proper functioning. Drainage greater than 70 ml/hour is a concern but does not require immediate reporting unless it continues at a high rate or is associated with other symptoms. Tidaling in the water seal chamber is a normal fluctuation and indicates the chest tube system is patent and functioning correctly.
You may also like to solve these questions
A client who is postoperative following abdominal surgery has an eviscerated wound. What should the nurse do first?
- A. Cover the incision with a moist sterile dressing.
- B. Notify the surgeon immediately.
- C. Assess the client's vital signs.
- D. Place the client in a supine position with knees bent.
Correct Answer: A
Rationale: The initial action the nurse should take after discovering a client's eviscerated wound is to cover the incision with a moist sterile dressing. This step is crucial to protect the exposed tissue, prevent infection, and create a conducive environment for healing. While notifying the surgeon is important, addressing the wound immediately takes precedence. Assessing vital signs is essential but should follow the immediate intervention of covering the wound. Placing the client in a supine position with knees bent is not the priority in managing an eviscerated wound; the first step is to cover the wound to protect the exposed tissue.
A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client's pain?
- A. Ask the client what precipitates the pain.
- B. Question the client about the location of the pain.
- C. Offer the client a pain scale to measure their pain.
- D. Use open-ended questions to identify the client's pain sensations.
Correct Answer: C
Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client's pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.
When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?
- A. Bleeding time
- B. Coagulation time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.
A client with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: Contact precautions are necessary when performing postmortem care on a client with MRSA to prevent the spread of infection. Contact precautions involve using barriers like gloves and gowns to limit direct contact with the deceased individual's body fluids and tissues. Airborne precautions are used for pathogens that are transmitted through the air, like tuberculosis. Droplet precautions are for pathogens that are transmitted through respiratory droplets, such as influenza. Compromised host precautions are not a recognized standard precaution type and are not applicable in this scenario.
A client tells the nurse, "I have to check with my partner and see if they think I am ready to go home." The nurse responds, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?
- A. Pacing
- B. Reflecting
- C. Paraphrasing
- D. Restating
Correct Answer: B
Rationale: Reflecting is the correct answer as it involves echoing back the client's feelings and concerns, helping them explore their thoughts. In this scenario, the nurse mirrors the client's statement to encourage the client to delve deeper into their emotions. Pacing involves matching the rate and flow of communication, paraphrasing is restating in different words, and restating is repeating what the client said without adding new information. Therefore, choices A, C, and D are not the appropriate clarifying technique demonstrated in the situation described.