Nokea
The nurse is caring for a client who had a portable water seal chest drainage system inserted today. Which observation indicates that the client's drainage system is working properly?
- A. There are no bubbles in the water seal bottle.
- B. The suction control chamber has continuous bubbles.
- C. There are bubbles in the drainage chamber.
- D. There is no fluctuation in the fluid in the water seal chamber.
Correct Answer: A
Rationale: No bubbles in the water seal bottle indicates a stable system without air leaks, confirming proper function post-insertion.
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A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
- A. Auscultate the client's breath sounds
- B. Encourage the client to increase fluid intake
- C. Report the findings to the supervising registered nurse
- D. Start an IV line for diuretic administration
Correct Answer: C
Rationale: Low urine output (200 mL/8 hr) in heart failure suggests worsening fluid retention, requiring immediate reporting to the RN (C). Auscultation (A), fluids (B), and IV diuretics (D) require RN direction.
When rendering aid to a victim who appears to be choking, the nurse's first action should be to:
- A. Administer a blow to the back.
- B. Ask the client whether she can speak.
- C. Administer a chest thrust.
- D. Establish an airway.
Correct Answer: B
Rationale: Asking if the victim can speak assesses airway obstruction severity. Back blows or chest thrusts follow if needed, and establishing an airway is not the first step.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone. Which of the following actions should the nurse take? Select all that apply.
- A. Administer vasopressin.
- B. Implement seizure precautions.
- C. Perform frequent neurological checks.
- D. Keep a strict record of fluid intake and output.
- E. Maintain an IV infusion of 0.9% sodium chloride.
Correct Answer: B,C,D
Rationale: Seizure precautions (B), neurological checks (C), and strict I&O (D) manage SIADH complications like hyponatremia. Vasopressin (A) worsens SIADH, and normal saline (E) may not correct hyponatremia.
The nurse is talking with a client who has a new prescription for misoprostol to prevent gastric ulcers. Which of the following statements by the client would require follow-up?
- A. I will take this medication with meals and at bedtime.
- B. I plan to use a reliable form of birth control while taking this medication.
- C. I can take this medication with an antacid to prevent an upset stomach.
- D. I should notify my health care provider if I develop black, tarry stools while taking this medication.
Correct Answer: C
Rationale: Taking misoprostol with antacids (C) reduces its efficacy and requires follow-up. Taking with meals (A), using contraception (B), and reporting black stools (D) are correct.
The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply.
- A. Allow the child to play with the stethoscope
- B. Begin with the child in the parent's lap
- C. Interact with the parent in a friendly manner
- D. Play with the child using a finger puppet
- E. Start by taking the child's vital signs
Correct Answer: A,B,C,D
Rationale: Playing with the stethoscope (A), starting in the parent's lap (B), friendly interaction (C), and using a puppet (D) reduce anxiety and enhance cooperation. Vital signs (E) may distress the child if done first.