Nokea
The nurse is caring for a client with a chest tube. Which of these assessments is a priority?
- A. Assessing for subcutaneous emphysema
- B. Assessing for signs of infection at the insertion site
- C. Monitoring the client's respiratory status
- D. Checking the chest tube for kinks or occlusions
Correct Answer: B
Rationale: Assessing for signs of infection at the insertion site is the priority when caring for a client with a chest tube. Infection at the insertion site can lead to serious complications such as empyema or sepsis. Monitoring respiratory status is essential but assessing for infection takes precedence to prevent immediate harm. Assessing for subcutaneous emphysema is important but not the priority unless it compromises respiratory function. Checking the chest tube for kinks or occlusions is crucial for proper drainage but is not the priority when infection is a concern.
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Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive stool culture for Shigella
- B. An elderly factory worker with a positive lab report for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination for Pneumocystis carinii from an induced sputum
- D. A middle-aged nurse with a history of varicella-zoster virus and crops of vesicles on an erythematous base appearing on the skin
Correct Answer: B
Rationale: The correct answer is B because a positive acid-fast bacillus smear in an elderly factory worker suggests tuberculosis, a serious communicable disease that must be reported promptly to the public health department to prevent its spread. Choice A is incorrect as Shigella is an important pathogen, but it does not require immediate public health reporting. Choice C is incorrect because Pneumocystis carinii is an opportunistic pathogen and does not require urgent public health reporting. Choice D is incorrect as varicella-zoster virus causes chickenpox and shingles, both of which are not reportable diseases to the public health department.
A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?
- A. A heart rate of 90 beats per minute
- B. A blood pressure of 120/80 mm Hg
- C. A respiratory rate of 16 breaths per minute
- D. A temperature of 98.6 degrees Fahrenheit
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.
Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing the doorway
- C. Knees bent, head slightly elevated, bed in the lowest position
- D. Bed in the lowest position, wheels locked, place bed against the wall
Correct Answer: D
Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.
A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares the elimination of which element?
- A. Sodium
- B. Potassium
- C. Phosphate
- D. Albumin
Correct Answer: B
Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps retain potassium while eliminating sodium. This is beneficial for patients with cirrhosis and ascites as they are at risk of low potassium levels. Choice A, Sodium, is incorrect as Spironolactone does not spare the elimination of sodium but rather helps eliminate it. Choice C, Phosphate, is incorrect as Spironolactone does not directly affect phosphate levels. Choice D, Albumin, is incorrect as Spironolactone does not spare the elimination of albumin.
A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?
- A. Why don't you switch to formula to ensure your baby is eating enough?
- B. It is common for new mothers to worry that they are not producing enough milk for their baby.
- C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
- D. Your newborn will need to remain in the hospital so his weight can be monitored.
Correct Answer: C
Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.