Nokea
The nurse is caring for a client with a history of a pneumothorax who has a chest tube in place. The nurse should:
- A. Clamp the chest tube during transport
- B. Strip the chest tube every hour
- C. Keep the drainage system below chest level
- D. Empty the drainage system daily
Correct Answer: C
Rationale: Keeping the drainage system below chest level prevents fluid backflow into the chest. Clamping risks pneumothorax, stripping is outdated, and emptying is per protocol, not daily.
You may also like to solve these questions
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
- A. Check FHT
- B. Notify the attending physician
- C. Turn off the IV oxytocin
- D. Prepare for the delivery because the client is probably in transition
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
Upon arrival to the nursery, Ilotycin (erythromycin) eyedrops are instilled in the newborn's eyes. The nurse understands that the medication will:
- A. Make the eyes less sensitive to light
- B. Help prevent neonatal blindness
- C. Strengthen the muscles of the eyes
- D. Improve accommodation to near objects
Correct Answer: B
Rationale: Erythromycin eyedrops are used prophylactically in newborns to prevent ophthalmia neonatorum, which can cause blindness.
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:
- A. I wouldn't want to go home either; call a friend who could help you.
- B. Did you do something that could have made him so angry?
- C. Let's talk about people and resources available to you so that you don't have to go home.
- D. I'll call the police and they will take care of him, and you can go home and get some rest.
Correct Answer: C
Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.
The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician?
- A. Sluggish bowel sounds
- B. Pain and tenderness at the umbilicus
- C. Passage of small amount of liquid stool
- D. Increasing abdominal girth
Correct Answer: D
Rationale: Increasing abdominal girth post-hemicolectomy may indicate complications like bleeding, ileus, or perforation, requiring immediate physician notification. Sluggish bowel sounds, umbilical pain, and liquid stool are expected early post-op.
Which of the following diagnoses require droplet precautions?
- A. Varicella
- B. Rubella
- C. Streptococcal pharyngitis
- D. Scarlet fever
- E. Shigella
- F. Hepatitis A
Correct Answer: B, C, D
Rationale: Rubella (B), streptococcal pharyngitis (C), and scarlet fever (D) are transmitted via respiratory droplets, requiring droplet precautions. Varicella (A) requires airborne precautions, while Shigella (E) and hepatitis A (F) are transmitted fecally-orally, requiring contact precautions.