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The nurse is caring for a client who has a chest tube connected to a wet suction closed chest drainage system. The nurse should recognize the drainage system is working correctly when gentle, continuous bubbling is present in the
- A. air leak gauge
- B. collection chamber
- C. water seal chamber
- D. suction control chamber
Correct Answer: D
Rationale: Gentle, continuous bubbling in the suction control chamber indicates proper suction in a wet suction system. Bubbling in the water seal suggests an air leak, and the collection chamber does not bubble.
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A 52-year-old woman who has thyroid cancer is treated with radioactive iodine (Iodotope). What should be included in the nursing care plan following administration of the drug? Select all that apply.
- A. Tell the client not to eat or drink anything for four hours.
- B. Tell the client not to sleep in the same room with anyone for seven days following administration.
- C. Save the client's urine in a lead container for 48 hours.
- D. Limit contact with the client to 30 minutes per person per shift on day 1.
- E. Assign client to a single room.
- F. Tell client to report weight gain and severe fatigue to health care provider.
Correct Answer: B,D,E,F
Rationale: Radioactive iodine requires isolation in a single room, limited contact (30 minutes/shift), separate sleeping for 7 days, and reporting symptoms like fatigue or weight gain (hypothyroidism). NPO or urine storage are not standard.
A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm?
- A. Atrial fibrillation
- B. Sinus rhythm with premature atrial contractions
- C. Sinus rhythm with premature ventricular contractions
- D. Ventricular tachycardia
Correct Answer: B
Rationale: The fluttering feeling and irregular rhythm suggest premature atrial contractions, often triggered by stimulants like energy drinks. Atrial fibrillation shows chaotic waves, ventricular contractions have wide QRS complexes, and ventricular tachycardia is life-threatening, not matching the description.
The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?
- A. Baked salmon with rice, steamed vegetables, and dinner roll
- B. Breaded pork chops, corn on the cob, and steamed snow peas
- C. Grilled chicken, green beans, and mashed potatoes
- D. Spaghetti with Italian tomato sauce and meatballs
Correct Answer: C
Rationale: Grilled chicken, green beans, and mashed potatoes are gluten-free, suitable for celiac disease. Dinner rolls, breaded pork chops, and spaghetti contain gluten, which must be avoided.
The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?
- A. projection
- B. displacement
- C. rationalization
- D. reaction formation
Correct Answer: B
Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.
The nurse is talking with a client who has gastroesophageal reflux disease and has been receiving long-term therapy with esomeprazole. Which of the following questions would be most important for the nurse to ask?
- A. Have you sustained any bone fractures recently?
- B. Are you experiencing an improved quality of sleep?
- C. Have you been checking your blood pressure regularly?
- D. Are you able to manage stressors in your life effectively?
Correct Answer: A
Rationale: Long-term esomeprazole use increases fracture risk due to reduced calcium absorption, making this the most critical question. Sleep, blood pressure, and stress are less directly related to esomeprazole’s side effects.