Nokea
John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
The level of the water in the water-seal chamber is at
- A. 2 cm
- B. -20 cm
- C. -10 cm
- D. -80 cm
Correct Answer: A
Rationale: The water-seal chamber is maintained at 2 cm to prevent air entry.
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In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:
- A. hypothyroidism
- B. hyperglycemia
- C. hypertension
- D. antiseizure medication
Correct Answer: A
Rationale: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.
The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions is MOST appropriate?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with headphones.
- C. Instruct the client to ignore the voices completely.
- D. Administer an antipsychotic medication as ordered.
Correct Answer: B
Rationale: Listening to music with headphones can distract from auditory hallucinations, reducing their intensity. Arguing (A) increases agitation, ignoring voices (C) is ineffective, and administering medication (D) is appropriate but not the most immediate non-pharmacologic intervention.
The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
- A. Raise the head of the bed at least 30 degrees
- B. Encourage ambulation within 24 hours
- C. Maintain in a flat position, logrolling as needed
- D. Encourage leg contraction and relaxation after 48 hours
Correct Answer: C
Rationale: Maintain in a flat position, logrolling as needed. The bed should remain flat for at least the first 24 hours to prevent injury.
The nurse is caring for a client with a fractured femur who is in skeletal traction. Which of the following actions is MOST important for the nurse to perform?
- A. Check the pin sites for signs of infection.
- B. Ensure the weights are hanging freely.
- C. Perform range-of-motion exercises on the affected leg.
- D. Reposition the client every 4 hours.
Correct Answer: B
Rationale: Ensuring weights hang freely maintains proper traction alignment, preventing complications like malunion. Checking pin sites (A) is important but secondary, ROM exercises (C) are contraindicated in traction, and repositioning (D) is limited to maintain traction.
A postoperative client is to be discharged today. She will need to change her dressing daily. Which statement she makes indicates that she understands the process?
- A. I will wash my hands before and after I change the dressing.'
- B. I can touch the dressings with my hands if I only touch the edges.'
- C. I should clean the area around the incision by moving the swab toward it.'
- D. I can put the old dressings directly in the waste basket.'
Correct Answer: A
Rationale: Hand washing before and after dressing changes prevents infection, reflecting proper understanding. Touching dressings, cleaning toward the incision, or improper disposal increase infection risk.