Nokea
The nurse is assisting with the removal of a client’s chest tube. Which of the following actions should the nurse take? Select all that apply.
- A. Ensure the client is given an analgesic 30-60 minutes before tube removal
- B. Instruct the client to breathe in, hold it, and bear down while the tube is being removed
- C. Place the client in the Trendelenburg position
- D. Prepare a sterile airtight petroleum jelly gauze dressing
- E. Provide the health care provider with sterile suture removal equipment
Correct Answer: A,B,D,E
Rationale: Analgesics reduce pain, Valsalva maneuver (bear down) prevents air entry, petroleum gauze seals the site, and suture equipment is needed. Trendelenburg is not indicated for chest tube removal.
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The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?
- A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
- B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
- C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
- D. Interrupt the dressing change to medicate the second client
Correct Answer: C
Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.
A client involved in a motor vehicle accident has a 4-inch laceration on her left lower leg. Which finding is consistent with an acute inflammatory reaction?
- A. Increased pain caused by the release of histamine
- B. Blanching of the skin proximal to the laceration
- C. A decrease in the white blood count
- D. Granulation of tissue at the edges of the laceration
Correct Answer: A
Rationale: Histamine release during acute inflammation causes pain and vasodilation. Blanching is not typical, white blood count increases, and granulation occurs later.
The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply.
- A. Avoid driving while taking this medicine
- B. Change positions slowly
- C. Discontinue immediately if suicidal thoughts occur
- D. Notify the health care provider of tarry stools
- E. Take the medicine with food
Correct Answer: D,E
Rationale: Tarry stools indicate potential GI bleeding, a serious naproxen side effect, and taking with food reduces GI irritation. Driving, position changes, and suicidal thoughts are not primary concerns with naproxen.
There have been several clients recently who have fallen in the long-term care facility. The nurse would like to reduce the number of falls. Which action is likely to do the most to help prevent falls?
- A. Ask the nursing assistants to watch the clients more closely.
- B. Restrain clients who cannot walk independently.
- C. Provide call bells so the clients can carry with them when they walk.
- D. Keep beds in the lowest position unless the nurse is performing care for the client.
Correct Answer: D
Rationale: Low bed height minimizes fall injury risk, a key prevention strategy. Closer watching, restraints, or call bells are less effective or restrictive.
The nurse is contributing to a staff education program about assessing the urinary system. Which statement by a nurse would indicate a correct understanding of the program?
- A. The bladder should be nontender and nonpalpable when it is empty
- B. Dark brown urine may indicate that the client has a urinary tract infection
- C. I should be able to palpate both kidneys regardless of the client’s abdominal girth
- D. I will assess for tenderness of the kidneys by performing blunt percussion over the client’s lower abdomen
Correct Answer: A
Rationale: An empty bladder is nontender and nonpalpable, indicating correct understanding. Dark brown urine suggests dehydration or other issues, not UTI; kidneys are not always palpable; and percussion is over the costovertebral angle, not lower abdomen.