Nokea
The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Absence of tidaling in the water seal chamber.
- C. Fluctuation of fluid in the drainage tube with respiration.
- D. No drainage in the collection chamber.
Correct Answer: C
Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.
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A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The nurse notes a respiratory rate of 30 breaths/min and oxygen saturation of 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Notify the physician
- C. Encourage deep breathing exercises
- D. Reposition the client to semi-Fowler's
Correct Answer: B
Rationale: An oxygen saturation of 88% and tachypnea indicate worsening hypoxia, requiring immediate physician notification for further orders. Increasing oxygen or repositioning may help but requires a prescription.
The nurse is developing a community health education program about sexually transmitted diseases. Which information about women who acquire gonorrhea should be included?
- A. Women are more reluctant than men to seek medical treatment.
- B. Gonorrhea is not easily transmitted to women who are menopausal.
- C. Women with gonorrhea are usually asymptomatic.
- D. Gonorrhea is usually a mild disease for women.
Correct Answer: C
Rationale: Women with gonorrhea are often asymptomatic, which increases the risk of delayed treatment and complications, a key point for education.
A therapeutic milieu is:
- A. A safe environment of care that is conducive to the prevention of medical errors.
- B. A client care area that provides personal privacy and the confidentiality of medical information.
- C. A European method of design and color to promote health and wellness.
- D. The provision of a therapeutic environment of consistency to promote health.
Correct Answer: D
Rationale: A therapeutic milieu is a structured environment designed to promote healing and recovery through consistency, safety, and therapeutic interactions.
The nurse administering a dose of scopolamine to a preoperative client should monitor the client for which common side effect of the medication?
- A. Dry mouth
- B. Diaphoresis
- C. Excessive urination
- D. Pupillary constriction
Correct Answer: A
Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication.
Select the complication of a blood transfusion that is accurately paired with its preventive measure.
- A. Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
- B. Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
- C. Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
- D. Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.