Nokea
The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Tubing clamped near the insertion site.
- C. Chest tube secured to the chest wall.
- D. Suction set at 20 cm H2O.
Correct Answer: B
Rationale: Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.
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Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to:
- A. Take NSAIDs at least three times per day.
- B. Exercise the joints at least 1 hour after taking the medication.
- C. Take antacids 1 hour after taking NSAIDs.
- D. Take NSAIDs with food.
Correct Answer: D
Rationale: Taking NSAIDs with food reduces gastrointestinal irritation and the risk of ulcers, a common side effect of these medications.
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hyperkalemia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent?
- A. The purpose of the proposed treatment or procedure
- B. The expected outcomes of the proposed treatment or procedure
- C. Who will perform the treatment or procedure
- D. When the procedure or treatment will be done
Correct Answer: D
Rationale: Essential components of informed consent include the purpose , expected outcomes , and who will perform the procedure . The specific timing is not a required minimal component.
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
A client has been prescribed transcutaneous electrical nerve stimulation (TENS) by the primary health care provider for the relief of chronic pain. Which statement by the client would indicate to the nurse a need for further teaching regarding this pain relief measure?
- A. I understand that this will help relieve the pain.
- B. This unit will eliminate the need for taking so many pain medications.
- C. I am not real happy that I have to stay in the hospital for this treatment.
- D. I am not sure that I am going to like those electrodes attached to my skin.
Correct Answer: C
Rationale: It is not necessary for the client to remain in the hospital for this treatment. The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes.