Nokea
The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:
- A. Add more water to the suction-control chamber
- B. Remove the drainage using a 60 mL syringe
- C. Milk the tubing to facilitate drainage
- D. Prepare a new unit for continuing collection
Correct Answer: D
Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.
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A client has a diagnosis of discoid lupus erythematosus (DLE). The nurse recognizes that discoid lupus differs from systemic lupus erythematosus because it:
- A. Produces changes in the kidneys
- B. Is confined to changes in the skin
- C. Results in damage to the heart and lungs
- D. Affects both joints and muscles
Correct Answer: B
Rationale: Discoid lupus erythematosus primarily affects the skin, causing chronic rashes, unlike systemic lupus, which can involve multiple organs.
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
During the nurse's assessment of a client who has been diagnosed with anorexia nervosa, the nurse evaluates certain characteristics that accompany an intense fear of gaining weight. What characteristics are most applicable? Select all that apply.
- A. fatigue
- B. excessive exercise regime
- C. normal weight
- D. high blood pressure
Correct Answer: A,B
Rationale: Fatigue and excessive exercise are common in anorexia nervosa due to malnutrition and compulsive behaviors. Normal weight or high blood pressure are less typical.
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
- A. reduce fluid intake to 1,500 ml/day
- B. take a warm shower twice a day
- C. apply a tight binder around her breasts
- D. come in to see the physician immediately as this is abnormal
Correct Answer: C
Rationale: A tight binder helps relieve breast engorgement by suppressing lactation in bottle-feeding mothers, a normal postpartum occurrence.
Which of the following findings are indicative of peripheral arterial insufficiency? Select all that apply.
- A. Throbbing, cramping pain that increases with exercise.
- B. Aching pain that increases with dependency.
- C. Capillary refill time of less than two seconds.
- D. Shiny skin with decreased hair.
- E. Brown pigment about the ankles and lower legs.
- F. Pale color on elevation and redness on dependency.
Correct Answer: A,D,F
Rationale: Peripheral arterial insufficiency causes throbbing pain with exercise (A), shiny skin with hair loss (D), and pale color on elevation with redness on dependency (F). Aching pain with dependency (B) and brown pigment (E) suggest venous insufficiency, and capillary refill <2 seconds (C) is normal.