Nokea
The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is
- A. reconnect the tube
- B. raise the collection chamber above the client's chest
- C. call the health care provider
- D. clamp the chest tube
Correct Answer: D
Rationale: Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client's chest is the first action to take, followed by health care provider notification.
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An adult is being discharged from the emergency room with instructions to apply a cold pack to his sprained ankle. The client asks why it is necessary to use a cold pack. The nurse replies that the cold pack will do which of the following?
- A. Keep the sprain from becoming a fracture
- B. Prevent bruising and ecchymosis from occurring
- C. Keep the client from developing a fever
- D. Help reduce swelling and pain
Correct Answer: D
Rationale: Cold packs reduce swelling and pain by constricting blood vessels and numbing the area, aiding sprain recovery. They don't prevent fractures, bruising, or fever.
The nurse is to open a sterile package. How should the nurse plan to open the first flap?
- A. Toward the nurse
- B. Away from the nurse
- C. To the right side
- D. To the left side
Correct Answer: B
Rationale: Opening the first flap away from the nurse maintains sterility by preventing hands from passing over the sterile field. Opening toward the nurse or to the sides risks contamination.
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM.
- A. What is the most appropriate action for a saturated dressing with dark, greenish-yellow drainage two hours after T-tube removal?
- B. Remove the dressing and replace it with a more absorbent dressing.
- C. Collect a culture and sensitivity specimen of the drainage.
- D. Observe the wound for dehiscence.
- E. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: Dark, greenish-yellow drainage is expected bile after T-tube removal. Replacing the saturated dressing with a more absorbent one keeps the site clean and dry, preventing infection. Cultures are unnecessary without infection signs, dehiscence is unlikely, and reinforcing risks infection.
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Tachycardia
- C. Ataxia
- D. Hypotension
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.
The nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments?
- A. Rely on child's self-report
- B. Use a peak-flow meter
- C. Note skin color changes
- D. Monitor pulse rate
Correct Answer: B
Rationale: The peak flow meter, if used correctly, shows effectiveness of inhalants.