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The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water-seal chamber.
- B. No fluctuation (tidaling) in the water-seal chamber.
- C. Intermittent bubbling in the suction control chamber.
- D. Drainage of clear, pale yellow fluid from the chest tube.
Correct Answer: D
Rationale: The drainage of clear, pale yellow fluid from the chest tube is an indication of proper chest tube functioning. Clear, pale yellow fluid signifies normal drainage from the pleural space without any signs of infection or complications. Choices A, B, and C are incorrect because continuous bubbling in the water-seal chamber, no fluctuation in the water-seal chamber, and intermittent bubbling in the suction control chamber are all indications of potential issues or malfunctioning of the chest tube system, which would require further assessment and intervention.
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The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?
- A. Lung sounds and respiratory status.
- B. Skin integrity and color.
- C. Neurological status and level of consciousness.
- D. Cardiac rate and rhythm.
Correct Answer: D
Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.
A community health nurse is conducting a program evaluation for a diabetes management class. Which measure best indicates the program's effectiveness?
- A. Number of participants attending each session
- B. Participant satisfaction with the class
- C. Reduction in participants' average blood glucose levels
- D. Improvement in participants' knowledge about diabetes
Correct Answer: C
Rationale: The most effective measure to indicate the program's effectiveness in a diabetes management class is the reduction in participants' average blood glucose levels. This measure directly reflects the impact of the program on managing diabetes and improving health outcomes. Choices A and B may provide valuable information but do not directly assess the program's impact on managing diabetes. Choice D, improvement in participants' knowledge about diabetes, is important but may not directly translate into improved diabetes management without actual health outcome measurements like blood glucose levels.
Several employees who have a 10-year or longer smoking history ask for assistance with smoking cessation. A nurse develops a 2-month program that includes weekly group sessions on lifestyle changes and use of over-the-counter nicotine substitute products. Which measurement provides the best indication of the program's effectiveness?
- A. survey employees to determine how many are smoking 2 months after the end of the program
- B. test the employees' knowledge of OTC nicotine substitute products at the end of the program
- C. ask employees to inform the group if they stop smoking and if they start smoking again
- D. design a questionnaire that identifies lifestyle changes contributing to smoking cessation
Correct Answer: A
Rationale: Surveying employees to determine how many are smoking 2 months after the end of the program provides a direct assessment of the program's effectiveness. This measurement evaluates the actual behavior change related to smoking cessation. Choice B, testing knowledge of OTC nicotine substitute products, does not directly measure smoking cessation outcomes. Choice C relies on self-reporting, which may not be accurate or reliable. Choice D focuses on identifying lifestyle changes but does not directly assess the program's impact on smoking cessation.
A public health nurse is evaluating a program designed to reduce the incidence of sexually transmitted infections (STIs) among teenagers. Which outcome indicates that the program is successful?
- A. increased attendance at educational sessions on STIs
- B. higher rates of condom use among teenagers
- C. more teenagers seeking testing for STIs
- D. greater knowledge of STI prevention methods
Correct Answer: B
Rationale: The correct answer is B: higher rates of condom use among teenagers. This outcome indicates that the teenagers are adopting safer sexual practices, which can effectively reduce the incidence of STIs. Increased attendance at educational sessions (Choice A) may show interest but does not directly reflect behavior change. More teenagers seeking testing for STIs (Choice C) indicates awareness but not necessarily prevention. Greater knowledge of STI prevention methods (Choice D) is valuable but does not guarantee behavioral change like increased condom use.
The healthcare provider is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?
- A. Serum potassium of 4.0 mEq/L and total calcium of 9 mg/dL.
- B. White blood cell count of 15,000/mm3.
- C. Serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL.
- D. Hemoglobin of 12 g/dL and phosphorus of 2 mg/dL.
Correct Answer: C
Rationale: In renal failure and osteodystrophy, there is an alteration in serum electrolyte balance. The correct answer is serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL. Renal failure is associated with hyperkalemia (elevated serum potassium) and hypocalcemia (low total calcium levels). Hyperphosphatemia is also commonly seen in renal failure. Choice A is incorrect as it describes normal levels of serum potassium and total calcium. Choice B is unrelated to the client's condition. Choice D is incorrect as it does not reflect the typical electrolyte imbalances seen in renal failure and osteodystrophy.