Nokea
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Drainage of 50 mL/hour
- D. Secured dressings around the tube site
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.
You may also like to solve these questions
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose?
- A. Warfarin sodium (Coumadin).
- B. Protamine sulfate.
- C. Acetylsalicylic acid (ASA).
- D. Atropine sulfate.
Correct Answer: B
Rationale: Protamine sulfate is the antidote for heparin overdose, neutralizing its anticoagulant effects.
A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which of the following should the nurse include as the action of spermicides when teaching the client?
- A. Destruction of spermatozoa before they enter the cervix.
- B. Prevention of spermatozoa from entering the uterus.
- C. A change in vaginal pH from acidic to alkaline.
- D. Slowing of the movement of the migrating spermatozoa.
Correct Answer: A
Rationale: Spermicides destroy spermatozoa before they can enter the cervix, preventing fertilization.
A client with a history of gout is prescribed febuxostat (Uloric). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Febuxostat can cause hepatotoxicity, requiring liver function monitoring.
Identify this cardiac rhythm strip. Fill in the blank. A. Third Degree Heart Block B. Second-Degree Atrioventricular Block, Type II C. Ventricular fibrillation D. Premature Atrial Contractions
- B. Third Degree Heart Block
- C. Second-Degree Atrioventricular Block, Type II
- D. Ventricular fibrillation
- E. Premature Atrial Contractions
Correct Answer: A
Rationale: Third Degree Heart Block shows complete dissociation between P waves and QRS complexes, assuming the strip matches this description.
The charge nurse on an antepartal unit is preparing to complete assignments for the day. There is an RN, licensed practical nurse (LPN), and an unlicensed personnel (UAP) to care for 25 clients. The nurse should assign which of the following clients to the:
- A. A newly admitted G5 P2 Ab 2 with second trimester bleeding, reportedly currently saturating 1-2 pads in 12 hours.
- B. A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in and out every 4 to 6 hours p.r.n. while awaiting urine cultures to be returned.
- C. A G4 P2 with a twin pregnancy who was admitted in preterm labor and is now able to ambulate 2 to 3 times daily and having no contractions.
- D. A 30-year-old G4 P0 who was admitted in sickle unless currently receiving blood and pain medication.
Correct Answer: C
Rationale: The client with a stable twin pregnancy who is ambulating and has no contractions can be assigned to the LPN or UAP, as this client requires less complex care compared to others with active medical issues.