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The nurse is caring for a client who had thoracic surgery yesterday and has a chest tube attached to water seal drainage. The client's family asks why he has to have a chest tube. What should the nurse include in the response?
- A. The chest tube allows air to enter the thoracic cavity to equalize pressures in the lung.
- B. The chest tube removes air from the pleural cavity and promotes reexpansion of the lung.
- C. The chest tube increases the amount of oxygen available to the lungs.
- D. The chest tube will help the wound heal faster and reduce scarring.
Correct Answer: B
Rationale: Chest tubes remove air/fluid from the pleural cavity, allowing lung reexpansion post-thoracic surgery. Other options misrepresent the tube's function.
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While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:
- A. Check the doctor's orders for an antipyretic.
- B. Ask the client whether he has received any medication for his fever.
- C. Call the nurse at home to validate whether the medication was given.
- D. Retake the client's temperature.
Correct Answer: D
Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.
Which of the following is a common complaint of the client with end-stage renal failure?
- A. Weight loss
- B. Itching
- C. Ringing in the ears
- D. Bruising
Correct Answer: B
Rationale: Itching is common in end-stage renal failure due to uremia and phosphate accumulation. Weight loss , tinnitus , and bruising are less specific.
The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply.
- A. Dress the infant in warm clothing and blankets
- B. Encourage smaller, frequent feedings
- C. Intervene quickly to prevent the infant from crying excessively
- D. Promote a quiet period on waking in the morning
- E. Turn the infant frequently during sleep
Correct Answer: B,C,D
Rationale: Smaller feedings, preventing crying, and quiet periods reduce oxygen demand, minimizing hypercyanotic spells. Warm clothing and frequent turning do not directly prevent spells.
Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?
- A. A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement
- B. A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
- C. A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement
- D. A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement
Correct Answer: B
Rationale: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement. When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.
A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?
- A. An 18 month-old who ate an undetermined amount of crystal drain cleaner
- B. A 14 month-old who chewed 2 leaves of a philodendron plant
- C. A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)
- D. A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
Correct Answer: A
Rationale: An 18 month-old who ate an undetermined amount of crystal drain cleaner. Orange juice is acidic and will help neutralize the alkaline drain cleaner.