Nokea
The nurse is caring for a client who had a chest tube inserted and attached to portable water seal drainage two days ago. There is no bubbling in the water seal chamber. What should the nurse assess initially?
- A. Observe the wound for excess drainage
- B. Check the system for air leaks
- C. Auscultate the lungs
- D. See if the suction is turned on
Correct Answer: C
Rationale: No bubbling may indicate lung reexpansion or system issues; auscultating lungs assesses reexpansion or complications like pneumothorax. Other assessments are secondary.
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The nurse has reinforced teaching with a client who has rheumatoid arthritis and is receiving methotrexate. Which of the following statements by the client would require follow-up?
- A. I will avoid drinking alcoholic beverages while taking methotrexate.'
- B. I should take precautions to prevent pregnancy while taking methotrexate.'
- C. I should avoid large crowds and people who are ill while taking methotrexate.'
- D. I will avoid consuming foods high in folic acid that will decrease the effectiveness of methotrexate.'
Correct Answer: D
Rationale: Avoiding alcohol (A), preventing pregnancy (B), and avoiding crowds (C) are correct. Avoiding folic acid (D) is incorrect, as methotrexate often requires folic acid supplementation to reduce side effects.
Laboratory reference ranges
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
The nurse is administering prescribed medications to assigned clients. The nurse should hold and seek clarification for which scheduled administrations? Select all that apply.
- A. client with cirrhosis had 2 stools today, lactulose prescribed daily
- B. client receiving IV vancomycin; mild facial flushing noted after 30 minutes
- C. client scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily
- D. client prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L)
- E. client with diabetes mellitus has insulin glargine and aspart prescribed, AM glucose is 100 mg/dL (5.6 mmol/L)
Correct Answer: B, C, D
Rationale: Vancomycin flushing (B) suggests red man syndrome, vitamin E (C) increases bleeding risk pre-surgery, and hyperkalemia (D) contraindicates lisinopril. Lactulose (A) and insulin (E) are appropriate.
A woman has recently been diagnosed with multiple sclerosis. Which comment by the client indicates that she understands the nature of the disease process?
- A. I understand that recovery will be slow.'
- B. I am faithfully taking the medicines so the symptoms should disappear soon.'
- C. I will avoid being close to my grandchildren until I have been on medication for several months.'
- D. I bought a pretty cane to help me with balance when I am walking.'
Correct Answer: D
Rationale: Using a cane for balance shows understanding of multiple sclerosis' chronic, progressive nature causing mobility issues, unlike expecting full recovery or avoiding grandchildren.
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?
- A. Teach her how to meet the needs of self and her family
- B. Explain the changes in diet necessary for pregnant women
- C. Question her understanding and use of the food pyramid
- D. Conduct a diet history to determine her normal eating routines
Correct Answer: D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.
A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply.
- A. Administer docusate sodium orally every day
- B. Assist in applying an abdominal binder
- C. Implement caloric restriction to promote weight loss
- D. Monitor blood glucose to maintain tight control
- E. Reinforce teaching to hug a pillow while coughing
Correct Answer: B, D, E
Rationale: Abdominal binder (B), glucose control (D), and pillow hugging (E) reduce wound stress and promote healing. Docusate (A) prevents constipation but not dehiscence, and caloric restriction (C) is inappropriate post-surgery.