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The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
- A. The system is intact.
- B. A pneumothorax is resolving.
- C. The suction to the system is shut off.
- D. There is an air leak somewhere in the system.
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
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The nurse is teaching a client with a new diagnosis of asthma about self-management. Which of the following instructions should be included?
- A. Use a peak flow meter daily.
- B. Avoid exercise to prevent attacks.
- C. Take bronchodilators daily.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Daily peak flow meter use monitors lung function and guides asthma management.
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
- A. Evidence of ruptured membranes.
- B. Viability status of the fetus.
- C. Indications that contractions have ceased.
- D. Fetal heart rate variability.
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
A client with a history of gastroesophageal reflux disease (GERD) is admitted with chest pain. The nurse should prioritize which of the following interventions?
- A. Obtain a 12-lead ECG.
- B. Administer omeprazole.
- C. Position the client supine.
- D. Administer an antacid.
Correct Answer: A
Rationale: Chest pain in GERD may mimic cardiac pain, so obtaining a 12-lead ECG rules out myocardial infarction.
A client with chronic kidney disease is on a low-potassium diet. Which food should the nurse advise the client to avoid?
- A. Apples.
- B. Bananas.
- C. Cauliflower.
- D. White bread.
Correct Answer: B
Rationale: Bananas are high in potassium, which must be limited in chronic kidney disease to prevent hyperkalemia.
A client has primary health care provider instructions to take ibuprofen 0.4 g for mild pain. The medication bottle contains ibuprofen 200-mg tablets. How many tablets will the nurse instruct the client to take for each dose? Fill in the blank. tablets
Correct Answer: 2
Rationale: To determine the number of tablets, divide the prescribed dose by the strength per tablet: 0.4 g = 400 mg; 400 mg ÷ 200 mg per tablet = 2 tablets. Therefore, the nurse instructs the client to take 2 tablets per dose.