Nokea
The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply.
- A. Place the client in the low Fowler's position.
- B. Assess chest tube drainage system frequently.
- C. Maintain strict bedrest for the client.
- D. Secure a loop of drainage tubing to the sheet.
- E. Observe the site for subcutaneous emphysema.
Correct Answer: B
Rationale: Frequent system checks (B), securing tubing (D), and monitoring emphysema (E) ensure chest tube function. Low Fowler’s (A) is incorrect (semi-Fowler’s preferred), and bedrest (C) is unnecessary.
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Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply:
- A. A 55-year-old male with hyperlipidemia and diabetes.
- B. A 70-year-old female with severe sepsis.
- C. A 25-year-old male who uses intravenous drugs.
- D. A 65-year-old female who is post-op day 1 after joint replacement surgery.
Correct Answer: B,C,D
Rationale: Virchow's Triad details the THREE factors for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. Patients who experience sepsis are at risk for hypercoagulability of the blood. Patients who use IV drugs damage the endothelial lining of the veins and this can lead to blood clot formation. Patients who've had joint replacement surgery are at risk for blood clots due to stasis of venous circulation etc.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
- A. The client's urine output is 100 mL in four (4) hours.
- B. The pulse oximeter reading is greater than 95%.
- C. The client has asymmetrical chest expansion.
- D. The telemetry reading shows sinus tachycardia.
Correct Answer: C
Rationale: Asymmetrical chest expansion (C) suggests pneumothorax, a ventilator complication. Low urine (A), SpO2 >95% (B), and tachycardia (D) are unrelated or expected.
Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT)
- C. Complete blood count (CBC) and hematocrit
- D. White blood cell (WBC) count and urinalysis
Correct Answer: B
Rationale: Liver function tests (AST and ALT) are essential before starting tuberculosis prophylaxis, as drugs like isoniazid can cause hepatotoxicity.
A patient taking Isoniazid (INH) should be monitored for what deficiency?
- A. Vitamin C
- B. Calcium
- C. Vitamin B6
- D. Potassium
Correct Answer: C
Rationale: This medication can lead to low Vitamin B6 levels. Most patients will take a supplement of B6 while taking this medication.
The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse?
- A. The client refuses to perform shoulder exercises.
- B. The client complains of a sore throat and is hoarse.
- C. The client has crackles that clear with cough.
- D. The client is coughing up pink frothy sputum.
Correct Answer: D
Rationale: Pink frothy sputum (D) suggests pulmonary edema, a life-threatening complication post-thoracotomy, requiring immediate intervention. Refusing exercises (A) needs addressing but is not urgent. Sore throat/hoarseness (B) may be from intubation, not critical. Crackles clearing with cough (C) are benign.