Nokea
The nurse caring for a client with closed chest drainage notes that the collection chamber is full.
- 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: A full collection chamber requires replacing the chest drainage unit to maintain effective drainage and prevent complications like tension pneumothorax.
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A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
- A. Urine output 22 mL/hr for 2 hours
- B. Serum potassium level of 3.7
- C. Small T wave of ECG
- D. Serum glucose level of 180
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
- A. Nutritional status
- B. Impaired thinking
- C. Possible harm to self
- D. Rest and activity impairment
Correct Answer: C
Rationale: Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
The nurse is teaching a client with a history of fibromyalgia about self-care. The nurse should tell the client to:
- A. Engage in regular exercise
- B. Avoid all physical activity
- C. Increase caffeine intake
- D. Use heating pads excessively
Correct Answer: A
Rationale: Regular, low-impact exercise can reduce pain and stiffness in fibromyalgia, improving overall function and well-being.
Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:
- A. Children seldom show concern about losing their hair
- B. The hair will come out gradually, and the loss will not be noticeable for some time
- C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out
- D. The parents will soon get used to seeing their children without hair, and it will no longer bother them
Correct Answer: C
Rationale: Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss.