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A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
- A. Your breathing pattern causes this.'
- B. This means your lung is fully re-expande '
- C. Suction pressure that is too high causes this.'
- D. This indicates a possible air leak.'
Correct Answer: A
Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system. Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber. Choice B is incorrect as lung re-expansion does not directly cause the fluid movement. Choice C is incorrect as high suction pressure does not cause this specific phenomenon. Choice D is incorrect as fluid movement does not indicate an air leak.
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A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A. Teaching the client how to self-medicate using the PCA device is essential to empower the client in managing their pain effectively. This promotes autonomy and ensures the client receives the appropriate dose at the right time, enhancing pain control. Choice B is incorrect as family members should not press the PCA button for the client to maintain safety and prevent medication errors. Choice C is incorrect as respiratory status should be monitored more frequently, ideally every 1-2 hours, when a client is receiving opioids due to the risk of respiratory depression. Choice D is incorrect as administering an oral opioid for breakthrough pain may lead to overdose or adverse effects when already receiving morphine through PCA.
A nurse is caring for a client who is experiencing an exacerbation of heart failure. Thenurse is
assessing the client 24 hr later. How should the nurse interpret the findings related to the
diagnosis of heart failure? For each finding, click to specify whe ther the finding is unrelated to
the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. Diagnostic Results
Hgb 8.4 g/dL (12 to 18 g/dL)
Hct 42% (37% to 47%)
WBC count 9,800/mm3 (5,000 to 10,000/ mm3) Potassium 432
mEq/L (3.5 to 5 mEq/L)
- A. Lung sounds clean
- B. Creatinine 1.8 mm/dl
- C. Weight 113kg(249 lb)
- D. WBC Count 11,800mm3
- E. Temperature: 38.5°C (101.3°F)
- F. Shortness of breath with exertion
Correct Answer: A, B,C,D,E
Rationale:
The correct answer is A, B, C, D, E. In heart failure exacerbation, key indicators are related to fluid overload and organ perfusion. A) Lung sounds clean indicate potential improvement in pulmonary congestion. B) Creatinine 1.8 mm/dl is important for kidney function monitoring, as worsening kidney function can occur in heart failure. C) Weight 113kg reflects fluid retention, relevant for heart failure management. D) WBC count (11,800mm3) can indicate infection, which can worsen heart failure. E) Temperature 38.5°C can suggest infection or systemic inflammatory response, which worsens heart failure.
A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I will limit my portions of meat to 8 ounces.
- B. I will increase my intake of canned vegetables.
- C. I will use canola oil when making salad dressing.
- D. I will drink whole milk with my cereal.
Correct Answer: C
Rationale: The correct answer is C: "I will use canola oil when making salad dressing." Canola oil is a healthier choice than other oils, as it is low in saturated fats and high in monounsaturated fats, which are beneficial for cardiovascular health. Using canola oil in salad dressing can help decrease the intake of unhealthy fats. Choice A is incorrect because limiting meat portions alone may not address overall dietary fat intake. Choice B is incorrect as canned vegetables may contain added sodium, which is not ideal for cardiovascular health. Choice D is incorrect as whole milk is high in saturated fats, not recommended for cardiovascular disease.
A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications?
- A. Nitroprusside
- B. Furosemide
- C. Epinephrine
- D. Desmopressin
Correct Answer: D
Rationale: The correct answer is D: Desmopressin. The client with a contusion of the brainstem and increased urinary output of 4,000 mL in 24 hrs is likely experiencing diabetes insipidus (DI), which is characterized by excessive urination and thirst. Desmopressin is a synthetic form of antidiuretic hormone (ADH) that helps reduce urine production and control thirst in DI. Nitroprusside (A) is a vasodilator used to treat hypertensive emergencies, not related to DI. Furosemide (B) is a loop diuretic that increases urine output and would worsen the client's condition. Epinephrine (C) is a sympathomimetic drug used in emergencies like anaphylaxis, not for DI. Therefore, Desmopressin is the most appropriate choice to address the client's symptoms.
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration?
- A. A client who has a history of asthma
- B. A client who has hypertension
- C. A client who has a history of migraines
- D. A client who has stable angina
Correct Answer: A
Rationale: The correct answer is A: A client who has a history of asthma. Propranolol is a non-selective beta-blocker that can potentially cause bronchoconstriction in clients with asthma due to its beta-2 antagonistic effects. The nurse should clarify the prescription with the provider for this client to avoid exacerbating respiratory issues. Choices B, C, and D are not contraindications for propranolol administration, as hypertension, migraines, and stable angina are conditions that can be treated with beta-blockers. It is important for the nurse to assess each client's medical history and consider potential contraindications before administering medications to ensure client safety and optimal outcomes.