Nokea
The healthcare provider is caring for a client with a chest tube following thoracic surgery. Which intervention should the healthcare provider include in the plan of care?
- A. Clamp the chest tube for 30 minutes every 2 hours.
- B. Milk the chest tube to ensure patency.
- C. Keep the drainage system at the level of the chest.
- D. Ensure that the chest tube is not clamped or kinked.
Correct Answer: D
Rationale: Ensuring that the chest tube is not clamped or kinked is essential to maintain proper drainage and prevent complications. Clamping the chest tube can lead to a buildup of pressure in the pleural space, causing potential harm to the client. Milking the chest tube is not recommended as it can cause damage to the delicate tubing. Keeping the drainage system at the level of the chest ensures proper drainage by gravity, preventing backflow of fluids, but ensuring the tube is not clamped or kinked takes precedence in this scenario.
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A client with a history of hypertension is admitted with acute renal failure. Which assessment finding requires immediate intervention?
- A. Blood pressure of 180/100 mm Hg.
- B. Urine output of 50 mL in 4 hours.
- C. Heart rate of 100 beats per minute.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Urine output of 50 mL in 4 hours indicates oliguria, which can be a sign of worsening renal function and requires immediate intervention. In acute renal failure, maintaining adequate urine output is crucial to prevent further kidney damage and manage fluid balance. A high blood pressure reading (Option A) is concerning but may not require immediate intervention in this scenario as it could be due to the history of hypertension. A heart rate of 100 beats per minute (Option C) is slightly elevated but may not be the most critical finding at this moment. Nausea and vomiting (Option D) are important to assess but are not as urgent as addressing oliguria in a client with acute renal failure.
The nurse is developing a workshop on cancer prevention for a group of adults at a wellness bar. Which recommendation should the nurse include in the workshop?
- A. know the 4 warning signs of cancer
- B. maintain a healthy weight and exercise regularly
- C. refrain from alcohol
- D. obtain at least 6 to 10 hours of sleep per night
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?
- A. Blood pressure of 160/90 mm Hg.
- B. Blood glucose level of 180 mg/dL.
- C. Difficulty speaking.
- D. Temperature of 99.8°F (37.7°C).
Correct Answer: C
Rationale: Difficulty speaking is a classic symptom of stroke, suggesting a potential blockage of blood flow to the brain. Prompt intervention is crucial to minimize brain damage. Elevated blood pressure (Choice A) may need management but is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) is within normal range and not a critical finding in this context.
The nurse is providing discharge teaching to a client with a new diagnosis of diabetes mellitus. Which statement by the client indicates a need for further teaching?
- A. I will need to monitor my blood sugar levels daily.
- B. I will follow a diet low in carbohydrates.
- C. I will rotate the injection sites for my insulin.
- D. I will exercise regularly to help manage my diabetes.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?
- A. I will increase my intake of vitamin C.
- B. I will avoid alcohol and tobacco.
- C. I will need to take folic acid supplements.
- D. I will avoid taking any medication without consulting my healthcare provider.
Correct Answer: D
Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy.