Nokea
The nurse is caring for a client who has a chest tube in place following a pneumothorax. The nurse notes that there is continuous bubbling in the water seal chamber of the chest tube drainage system. What action should the nurse take?
- A. Check for kinks in the tubing
- B. Notify the healthcare provider
- C. Replace the chest tube drainage system
- D. Reinforce the chest tube dressing
Correct Answer: B
Rationale: The correct action for the nurse to take when observing continuous bubbling in the water seal chamber of the chest tube drainage system is to notify the healthcare provider. Continuous bubbling indicates a possible air leak, and the healthcare provider needs to be informed to assess the situation and take appropriate actions. Checking for kinks in the tubing (Choice A) may be done initially but is not the priority when continuous bubbling is present. Replacing the chest tube drainage system (Choice C) and reinforcing the chest tube dressing (Choice D) are not immediate actions needed in response to continuous bubbling in the water seal chamber.
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When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?
- A. I will use crutches to keep my weight off my knee
- B. I will stay home until a wheelchair is delivered
- C. I can use the trapeze bar and side rails on the bed to help me turn regularly
- D. I can put my full weight on my foot starting the day after surgery
Correct Answer: A
Rationale: The correct answer is A. Using crutches indicates an understanding of weight-bearing restrictions post-surgery. Choice B is incorrect because waiting for a wheelchair is not related to postoperative mobility instructions. Choice C is incorrect as turning in bed using the trapeze bar and side rails does not address weight-bearing restrictions. Choice D is incorrect because putting full weight on the foot immediately after surgery contradicts the need to keep weight off the knee.
A client with chronic renal failure is being discharged with a prescription for erythropoietin (Epogen). Which statement indicates that the client understands the action of this medication?
- A. It helps my body make red blood cells
- B. It helps prevent infections
- C. It helps my kidneys excrete excess fluid
- D. It helps me breathe easier
Correct Answer: A
Rationale: The correct answer is A: 'It helps my body make red blood cells.' Erythropoietin is a medication that stimulates the production of red blood cells in the body. Clients with chronic renal failure often develop anemia due to decreased erythropoietin production by the kidneys. This medication helps address that issue by increasing red blood cell production. Choices B, C, and D are incorrect because erythropoietin does not prevent infections, help kidneys excrete excess fluid, or assist with breathing; its primary action is to boost red blood cell production.
An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct Answer: B
Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.
A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
- A. Risk for impaired tissue integrity related to impaired physical mobility
- B. Impaired skin integrity related to altered circulation and pressure
- C. Ineffective tissue perfusion related to inability to move self in bed
- D. Impaired physical mobility related to the left side paralysis
Correct Answer: B
Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.
Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?
- A. Dorsiflexes the right foot and left on command
- B. A 3 by 5 cm ecchymosis area covering the right calf
- C. Right calf is 3 cm larger in circumference than the left
- D. Bilateral lower extremity has 3+ pitting edema
Correct Answer: C
Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.