Nokea
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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An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. After reviewing the results of the analysis, the nurse recognizes that the CSF is normal when which element is negative?
- A. Protein
- B. Glucose
- C. Red blood cells
- D. White blood cells
Correct Answer: C
Rationale: The adult with a normal CSF has no red blood cells in the CSF. Protein (15-45 mg/dL [0.15-0.45 g/L]) and glucose (50-75 mg/dL [2.8-4.2 mmol/L]) are normally present in CSF. The client may have small levels of white blood cells (0-5 cells/mcL [0-5 × 10^6/L]).
The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction should the nurse include?
- A. To avoid driving a car for at least 2 weeks
- B. Not to be fitted for a prosthesis for at least 3 months
- C. To avoid sitting for long periods for at least 2 weeks
- D. To report any elevation in temperature to the primary health care provider
Correct Answer: D
Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive. Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostate surgery because of the risk of hemorrhage, but this risk is not as high with testicular surgery.
The nurse is performing pin-site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites?
- A. Loose but intact pin sites
- B. Clear drainage from the pin sites
- C. Purulent drainage from the pin sites
- D. Redness and swelling around the pin sites
Correct Answer: B
Rationale: A small amount of clear drainage ('weeping') may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Pins should not be loose; if this is noted, the primary health care provider should be notified. Purulent drainage and redness and swelling around the pin sites may be indicative of an infection.
The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions should the nurse implement? Select all that apply.
- A. Stop movement of the affected part.
- B. Massage the affected part vigorously.
- C. Notify the primary health care provider immediately.
- D. Force movement of the joint supporting the muscle.
- E. Ask the client to stand and walk rapidly around the room.
- F. Place continuous gentle pressure on the muscle group until it relaxes.
Correct Answer: A,F
Rationale: ROM exercises should put each joint through as full a range of motion as possible without causing discomfort. An unexpected outcome is the development of spastic muscle contraction during ROM exercises. If this occurs, the nurse should stop movement of the affected part and place continuous gentle pressure on the muscle group until it relaxes. Once the contraction subsides, the exercises are resumed using slower, steady movement. Massaging the affected part vigorously may worsen the contraction. There is no need to notify the primary health care provider unless intervention is ineffective. The nurse should never force movement of a joint. Asking the client to stand and walk rapidly around the room is an inappropriate measure.
A client is diagnosed with diabetes insipidus. The nurse should plan interventions to address which manifestations of this disorder? Select all that apply.
- A. Bradycardia
- B. Hypertension
- C. Poor skin turgor
- D. Increased urinary output
- E. Dry mucous membranes
- F. Decreased pulse pressure
Correct Answer: C,D,E,F
Rationale: Diabetes insipidus is a water metabolism problem caused by an antidiuretic hormone (ADH) deficiency (either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH). Clinical manifestations include poor skin turgor, increased urinary output, dry mucous membranes, decreased pulse pressure, tachycardia, hypotension, weak peripheral pulses, and increased thirst.