NCLEX RN Client Needs Physiological Adaptation

NCLEX RN Client Needs Physiological Adaptation Related

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The nurse is assisting a client with a chest tube to get out of bed, when the chest tubing accidentally gets caught in the bed rail and disconnects. While trying to reestablish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse should take which action to minimize the client's risk for injury?

  • A. Clamp the chest tube.
  • B. Call the primary health care provider.
  • C. Apply a petroleum gauze over the end of the chest tube.
  • D. Immerse the chest tube in a bottle of sterile water or normal saline.
Correct Answer: D

Rationale: If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube or, in this case, immersing the end of the chest tube 1 to 2 inches below the surface of a 250-mL bottle of sterile water or normal saline until a new chest tube can be set up. The primary health care provider should be notified but only after taking corrective action. If the primary health care provider is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause tension pneumothorax. A petroleum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from the chest.

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The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?

  • A. Takes blood pressures in the right arm only
  • B. Draws serum laboratory samples from the right arm only
  • C. Positions the client supine and flat with the right arm elevated on a pillow
  • D. Checks the right posterior axilla area when assessing the surgical dressing
Correct Answer: D

Rationale: If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. Blood pressure measurement, venipuncture, and intravenous sites should not involve use of the operative arm. The client should be positioned with the head in semi-Fowler's position and the arm on the operative side elevated on pillows to decrease edema.

The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?

  • A. Maintain an open airway.
  • B. Administer oxygen by face mask.
  • C. Assess the maternal blood pressure and fetal heart tones.
  • D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A

Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.

The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?

  • A. Change the drainage bag to a leg collection bag.
  • B. Tie the drainage bag to the client's waist while ambulating.
  • C. Use a walker to hang the drainage bag from while ambulating.
  • D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A

Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.

The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a client. When administering the IV potassium chloride, which action should the nurse take?

  • A. Inject it as a bolus.
  • B. Use a filter in the IV line.
  • C. Dilute it per medication instructions.
  • D. Apply cool compresses to the IV site.
Correct Answer: C

Rationale: Potassium chloride is very irritating to the vein and must be diluted to prevent phlebitis and is administered using an IV pump. Potassium chloride is never administered as a bolus injection because it can cause cardiac arrest. A filter is not necessary for potassium solutions. Cool compresses would constrict the blood vessel, which could possibly be more irritating to the vein.

During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report?

  • A. Weight gain
  • B. Night sweats
  • C. Severe lymph node pain
  • D. Headache with minor visual changes
Correct Answer: B

Rationale: Assessment of a client with Hodgkin's disease most often reveals night sweats; enlarged, painless lymph nodes; fever; and malaise. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.

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