Nokea
The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. Which action is appropriate based on this assessment?
- A. Document the tidaling.
- B. Elevate the head of the bed and notify charge nurse of malfunction of drainage system.
- C. Add more sterile water to the water seal chamber.
- D. Turn patient to the affected side.
Correct Answer: A
Rationale: Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding.
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In which way should a patient be positioned after a thoracentesis is completed and the dressing applied?
- A. High Fowler
- B. Semi-Fowler
- C. Side lying on unaffected side
- D. Prone
Correct Answer: C
Rationale: After a thoracentesis, the patient is placed in a side-lying position on the unaffected side.
A patient comes to the health nurse at the workplace with epistaxis. The patient reports frequent nosebleeds that have usually been controlled without intervention. Which assessment would be the most helpful after the nurse has stopped the bleeding?
- A. Obtain a blood pressure.
- B. Record the approximate amount of blood lost.
- C. Inquire about a headache.
- D. Record the last episode of epistaxis.
Correct Answer: A
Rationale: Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis. In addition, epistaxis can be a complication of untreated hypertension.
Which important precaution should the nurse include when instructing a patient with emphysema on the use of home oxygen?
- A. Use oxygen only when extremely short of breath.
- B. Keep the home oxygen regulator set on 6 L.
- C. Use home oxygen at night while sleeping.
- D. Limit to 1 to 2 L oxygen flow.
Correct Answer: D
Rationale: Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the body's own respiratory regulatory centers and can cause respiratory failure.
When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger with which consideration?
- A. on the same side as the blood pressure cuff.
- B. while exercising the arm to stimulate circulation.
- C. that is a normal temperature.
- D. on the same side as an arterial catheter.
Correct Answer: C
Rationale: The pulse oximeter should be placed on a finger of the hand that is normal temperature because hypothermia will affect the reading. The device should not be put on a finger on the same side as a blood pressure cuff or arterial line.
A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a 'barrel chest.' Which pathology causes this to occur?
- A. An increase in the lateromedial area from hypertrophy of mucous glands in the bronchi
- B. An increased anteroposterior diameter caused by overinflation of the alveoli
- C. A decrease in anteroposterior diameter caused by chronic dilation of the bronchi
- D. A widening of the sternocostal area secondary to chronic constriction of smooth muscles in the airways leading to bronchospasms
Correct Answer: B
Rationale: The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation).