Nokea
The nurse is assessing teenaged girls at a well child clinic. The nurse should describe the girl shown in the figure as having:
- A. Normal posture
- B. Kyphosis
- C. Scoliosis
- D. Lordosis
Correct Answer: C
Rationale: Scoliosis is characterized by a lateral curvature of the spine, which may be observed in a teenager. Kyphosis involves forward curvature, lordosis involves inward lumbar curvature, and normal posture lacks these abnormalities.
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The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Absence of tidaling in the water seal chamber.
- C. Fluctuation of fluid in the drainage tube with respiration.
- D. No drainage in the collection chamber.
Correct Answer: C
Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?
- A. To control bleeding in the bladder.
- B. To instill antibiotics into the bladder.
- C. To keep the catheter free from clot obstruction.
- D. To prevent bladder distention.
Correct Answer: C
Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
- A. Remove the inner cannula every 2 hours for cleaning.
- B. Secure the tracheostomy ties with a square knot.
- C. Use cut gauze under the neck plate to protect the skin.
- D. Suction the inner cannula on completion of the procedure.
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
A client is receiving a continuous I.V. infusion of heparin. The nurse should monitor the client for which of the following adverse effects?
- A. Hypotension.
- B. Bleeding.
- C. Hypoglycemia.
- D. Tachycardia.
Correct Answer: B
Rationale: Heparin is an anticoagulant, and its primary adverse effect is bleeding, which the nurse should monitor closely.
The nurse should give which medication instructions to the client prescribed quinapril hydrochloride?
- A. Take the medication with food only.
- B. Expect a therapeutic effect immediately.
- C. Discontinue the medication if nausea occurs.
- D. Rise slowly from a lying to a sitting position.
Correct Answer: D
Rationale: Quinapril hydrochloride is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. A full therapeutic effect may be noted in 1 to 2 weeks. If nausea occurs, the client should be instructed to take a noncola carbonated beverage and salted crackers or dry toast.