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The nurse is caring for a client with a chest tube. Which finding indicates a potential complication?
- A. Continuous bubbling in the water seal chamber.
- B. Fluctuation in the water seal with breathing.
- C. Serosanguineous drainage.
- D. Pain at the insertion site.
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate attention.
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A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization?
- A. A plastic model of the heart.
- B. A catheter that will be inserted into the artery.
- C. The parents.
- D. Other children undergoing a catheterization.
Correct Answer: C
Rationale: Including the parents in teaching provides emotional support and reassurance to the child, which is critical for a 4-year-old facing a procedure. While a model or catheter explanation may be useful, parental presence is most important for the child's comfort and understanding.
To protect a client who has received tissue plasminogen activator (t-PA, or Activase) therapy, the nurse should:
- A. Use the radial artery to obtain blood gas samples.
- B. Maintain arterial pressure for 10 seconds.
- C. Administer I.M. injections.
- D. Encourage physical activity.
Correct Answer: B
Rationale: Maintaining pressure on arterial puncture sites for 10 seconds minimizes bleeding risk, critical after t-PA due to its thrombolytic effects.
Buspirone hydrochloride is prescribed for a client diagnosed with an anxiety disorder. The nurse providing instructions should inform the client about which characteristic of this medication?
- A. There is risk of addiction.
- B. Dizziness and nausea may occur.
- C. Tolerance can occur with the medication.
- D. The medication can produce a sedating effect.
Correct Answer: B
Rationale: Buspirone hydrochloride is used in the management of anxiety disorders. The medication has a more favorable side effect profile than do the benzodiazepines. Dizziness, nausea, headaches, lightheadedness, and paradoxical central nervous system excitement, which generally are not major problems, are side effects of the medication. The advantages of this medication are that it is not addicting, tolerance does not develop, and it is not sedating.
A client with a history of renal calculi is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
- A. Increase fluid intake.
- B. Avoid dairy products.
- C. Take the medication with meals.
- D. Stop the medication if pain resolves.
Correct Answer: A
Rationale: Increased fluid intake prevents stone formation while taking allopurinol for uric acid stones.
The nurse identifies the type of presentation shown in the fi gure as which of the following?
- A. Frank breech.
- B. Compound breech.
- C. Complete breech.
- D. Incomplete breech.
Correct Answer: C
Rationale: For a complete breech, the buttocks present, the feet and legs are fl exed on the thighs, and the thighs are fl exed on the abdomen. For a frank breech, the buttocks present with the hips fl exed and the legs extended against the abdomen and chest. This is the most common type of breech presentation. For a compound breech, the buttocks present together with another part, such as a hand. This is a rare occurrence. For an incomplete breech, one or both feet or the knees extend below the buttocks. This can also be termed a single footling or double footling breech.