Nokea
The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What intervention should the nurse implement?
- A. Unkinking the tubing
- B. Assessing for an air leak
- C. Documenting that the lung has reexpanded
- D. Documenting that the lung has not yet reexpanded
Correct Answer: D
Rationale: Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate occlusion of the tubing or that the lung has reexpanded. Excessive bubbling in the water seal chamber indicates that an air leak is present.
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Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
- A. Assess peripheral circulation.
- B. Monitor for abdominal distention.
- C. Educate the client that abdominal pain is to be expected.
- D. Assess the client for observable ecchymoses on the lower back.
- E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
Correct Answer: A,B,D
Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.
The nurse provides information to a client diagnosed with gastroesophageal reflux disease (GERD). What information should the nurse include when discussing foods that contribute to decreased lower esophageal sphincter (LES) pressure and thus worsen the condition? Select all that apply.
- A. Alcohol
- B. Fatty foods
- C. Citrus fruits
- D. Baked potatoes
- E. Caffeinated beverages
- F. Tomatoes and tomato products
Correct Answer: A,B,C,E,F
Rationale: GERD occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus. The most common cause of GERD is inappropriate relaxation of the LES, which allows the reflux of gastric contents into the esophagus and exposes the esophageal mucosa to gastric contents. Factors that influence the tone and contractility of the LES and lower LES pressure include alcohol; fatty foods; citrus fruits; caffeinated beverages such as coffee, tea, and cola; tomatoes and tomato products; chocolate; nicotine in cigarette smoke; calcium channel blockers; nitrates; anticholinergics; high levels of estrogen and progesterone; peppermint and spearmint; and nasogastric tube placement. Baked potatoes would not contribute to worsening the problem.
A client undergoes transurethral resection of the prostate (TURP). Which solution should the nurse have available postoperatively for continuous bladder irrigation (CBI)?
- A. Sterile water
- B. Sterile normal saline
- C. Sterile Dakin's solution
- D. Sterile water with 5% dextrose
Correct Answer: B
Rationale: Continuous bladder irrigation is done after TURP using sterile normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly kidney failure. Dakin's solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not introduced into the bladder.
The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? Select all that apply.
- A. Minimize the force and friction applied to the skin.
- B. Massage vigorously over bony prominences twice daily.
- C. Perform a systematic skin inspection at least once a day.
- D. Cleanse the skin at the time of soiling and at routine intervals.
- E. Use pillows to keep the knees and other bony prominences from direct contact with one another.
- F. Use hot water and a mild cleansing agent that minimizes irritation and dryness of the skin when bathing the client.
Correct Answer: A,C,D,E
Rationale: The client in this question is at high risk for pressure injury. Interventions for prevention of pressure injuries include minimizing the force and friction applied to the skin; performing a systematic skin inspection at least once a day, giving particular attention to the bony prominences; cleansing the skin at the time of soiling and at routine intervals; avoiding the use of hot water; and using a mild cleansing agent that minimizes irritation and dryness of the skin. Pillows should be used to keep the knees and other bony prominences from direct contact with one another, because skin contact can promote breakdown. Massaging over bony prominences (especially vigorous) can be harmful to at-risk skin surfaces.