Nokea
The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?
- A. Section A
- B. Section B
- C. Section C
- D. Section D
Correct Answer: A
Rationale: Bubbling in the water seal chamber indicates an air leak from the lung or tubing. The suction control chamber bubbles with suction, and the collection chamber collects fluid, not air.
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A client is admitted with pernicious anemia. The client reports all of the following. Which is most likely related to the admitting diagnosis?
- A. I often have diarrhea.'
- B. My tongue is more red and thick than usual.'
- C. I have little bruise-like spots on my arms and legs.'
- D. I have been running a fever for the last two days.'
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes a sore, red, beefy tongue. Diarrhea, bruising, or fever are less specific.
An adult woman who broke her right ankle is seen in the physician's office one week after the cast was applied. Which observation indicates to the office nurse that the client is using crutches correctly?
- A. The client moves the left crutch forward, then the right foot, then the right crutch, and finally the left foot.
- B. The client moves the left crutch and the right foot together, and then moves the right crutch and the left foot together.
- C. The client moves the left foot and the crutches forward while bearing weight on the right foot.
- D. The client bears weight on the left foot, and then moves the right foot and the crutches forward.
Correct Answer: A
Rationale: The four-point crutch gait (left crutch, right foot, right crutch, left foot) is stable and correct for a non-weight-bearing right ankle, ensuring balance and safety.
The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?
- A. I'm glad that I can continue taking my Ginkgo biloba.
- B. I will increase my intake of leafy green vegetables
- C. I will start applying vitamin E to my chest incision after showering
- D. I will shave with an electric razor from now on
Correct Answer: D
Rationale: Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding.
Laboratory reference ranges
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L)
The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?
- A. Serum glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L)
- B. Client is lying with knees drawn up to the abdomen to alleviate pain
- C. Temperature is 102.2°F (39°C) with increasing abdominal pain
- D. Five large, liquid stools are yellow and foul-smelling
Correct Answer: C
Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.
The nurse is caring for a client with a suspected stroke who is scheduled for a CT scan of the head. Which of the following assessments would be a priority for the nurse to make prior to the CT scan?
- A. Assess for a history of asthma
- B. Check the client’s blood glucose level
- C. Obtain a set of vital signs
- D. Verify whether the client has any allergies to contrast media
Correct Answer: D
Rationale: Allergies to contrast media are critical to assess before a CT scan to prevent anaphylaxis. Asthma, glucose, and vital signs are important but secondary to contrast safety.