Nokea
The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
- A. The water seal chamber is bubbling continuously.
- B. The drainage system is positioned below the client’s chest.
- C. The chest tube is taped securely to the chest.
- D. The client is lying on the affected side.
Correct Answer: D
Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.
You may also like to solve these questions
The nurse is caring for a client with a history of Addison’s disease. The nurse should expect the client to have:
- A. Hypotension
- B. Hypertension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Addison’s disease causes adrenal insufficiency, reducing cortisol and aldosterone, leading to hypotension due to fluid and sodium loss.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- A. Brushing the teeth
- B. Drinking a glass of juice
- C. Holding a cup of coffee
- D. Brushing the hair
Correct Answer: C
Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and encouraging gentle hand movement. The other activities do not specifically alleviate joint stiffness.
The physician has ordered DDAVP (desmopressin acetate) for a client with diabetes insipidus. Which finding indicates that the medication is having its intended effect?
- A. The client's appetite has improved.
- B. The client's morning blood sugar was 120 mg/dL.
- C. The client's urinary output has decreased.
- D. The client's activity level has increased.
Correct Answer: C
Rationale: DDAVP reduces excessive urination in diabetes insipidus by mimicking antidiuretic hormone, decreasing urinary output. Appetite, blood sugar, and activity are not directly affected.
Which of the following should be included in discharge teaching for a client with hepatitis C?
- A. He should take aspirin as needed for muscle and joint pain.
- B. He may become a blood donor when his liver enzymes return to normal.
- C. He should avoid alcoholic beverages during his recovery period.
- D. He should use disposable dishes for eating and drinking.
Correct Answer: C
Rationale: Alcohol should be avoided as it is detoxified by the liver, which is compromised in hepatitis C. Aspirin is hepatotoxic, blood donation is not allowed, and hepatitis C is not spread orally.
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?
- A. Promises of gifts that her husband made to her
- B. Acute battering of the client, characterized by his volatile discharge of tension
- C. Minor battering incidents, such as the throwing of food or dishes at her
- D. A period of tenderness between the couple
Correct Answer: C
Rationale: This description is characteristic of the 'tension-building' phase prior to the volatile discharge of tension found in the battering phase.