Nokea
The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- A. Intermittent bubbling in the water seal chamber.
- B. Drainage of 75 ml in the first hour post-insertion.
- C. Crepitus around the insertion site.
- D. Fluctuation of the water level in the water seal chamber with respiration.
Correct Answer: C
Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications.
A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system.
B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored.
D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.
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A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?
- A. Chorionic villus sampling under ultrasound.
- B. Amniocentesis and fetal monitoring.
- C. Ultrasonography and nonstress test.
- D. Oxytocin challenge test and fetal heart rate monitoring.
Correct Answer: C
Rationale: The correct answer is C: Ultrasonography and nonstress test. At 38 weeks gestation, a biophysical profile (BPP) is typically done to assess fetal well-being. Ultrasonography is used to evaluate fetal movements, tone, breathing movements, and amniotic fluid volume. The nonstress test assesses fetal heart rate in response to fetal movement, indicating fetal well-being. Chorionic villus sampling (A) and amniocentesis (B) are invasive procedures not typically done as part of a routine BPP. Oxytocin challenge test (D) is not indicated in this scenario as it is used to assess placental function in high-risk pregnancies.
The healthcare provider is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?
- A. Weigh the child daily.
- B. Observe the lower extremities for pitting edema.
- C. Measure the child's abdominal girth weekly.
- D. Weigh the child's wet diapers.
Correct Answer: A
Rationale: The correct answer is A: Weigh the child daily. Daily weight monitoring is the most accurate way to determine fluid retention in a child with nephrotic syndrome as it provides real-time data on fluid status. Weight gain is a key indicator of fluid retention in these patients. Observing lower extremities for pitting edema (B) is subjective and may not accurately reflect fluid status. Measuring abdominal girth weekly (C) may not provide timely information on fluid retention. Weighing wet diapers (D) does not give a comprehensive picture of total fluid retention and may not be as accurate as daily weight monitoring.
The client is prescribed clozapine (Clozaril), and the nurse plans to educate them about its purpose. Which statement should the nurse provide?
- A. It will help you function better in the community.
- B. The medication will help you think more clearly.
- C. You will be able to cope with your symptoms.
- D. It will improve your grooming and hygiene.
Correct Answer: B
Rationale: The correct answer is B: "The medication will help you think more clearly." This is the most appropriate statement to educate the client about clozapine. Clozapine is an antipsychotic medication used to treat schizophrenia and helps with cognitive symptoms such as disorganized thinking. Choice A is too vague and doesn't specify the medication's intended effect. Choice C is too general and doesn't focus on cognitive improvement. Choice D is incorrect as clozapine does not specifically target grooming and hygiene but rather cognitive symptoms.
A 62-year-old male client with a history of coronary artery disease complains that his heart is 'racing' and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, which prescription should the nurse administer?
- A. Give magnesium via secondary infusion.
- B. Initiate IV heparin solution as per protocol.
- C. Administer IV adenosine (Adenocard).
- D. Prepare for synchronized cardioversion.
Correct Answer: C
Rationale: The correct answer is C: Administer IV adenosine (Adenocard).
Rationale:
1. The ECG rhythm shows regular narrow complex tachycardia, likely supraventricular tachycardia (SVT).
2. Adenosine is the first-line medication for terminating SVT by blocking conduction through the AV node.
3. Adenosine is given rapidly as a bolus dose followed by a saline flush to ensure quick delivery to the heart.
4. Adenosine has a very short half-life, making it safe to use in this scenario.
Summary:
A: Magnesium is not the first-line treatment for SVT.
B: Heparin is not indicated for the management of SVT.
D: Synchronized cardioversion is reserved for unstable patients with hemodynamic compromise, not indicated for stable SVT.
A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct Answer: C
Rationale: The correct answer is C because sitting with the client and offering support without demanding participation is crucial in building trust and rapport. This approach respects the client's autonomy and allows them to feel supported without pressure. It also creates a safe space for the client to open up when they are ready.
Explanation for why the other choices are incorrect:
A: Offering high-calorie snacks and frequent small meals does not address the core issue of the client's refusal to participate in therapy.
B: Asking the client why they are not participating in therapy may come off as confrontational and could further discourage them from opening up.
D: Encouraging the client to discuss their feelings of hopelessness may be overwhelming for them at this stage and could lead to resistance.