Nokea
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water-seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Continuous bubbling in the water seal chamber
- C. Absence of bubbling in the water seal chamber
- D. No drainage in the collection chamber
Correct Answer: A
Rationale: Fluctuation (tidaling) in the water-seal chamber during inspiration and expiration indicates the chest tube is functioning properly.
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A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?
- A. Ask about the client's exposure to any past or present STIs.
- B. Advise clients not to disclose their sexual history.
- C. Focus only on present symptoms of STIs.
- D. Only ask about high-risk behavior.
Correct Answer: A
Rationale: The correct answer is A because asking about the client's exposure to any past or present STIs is crucial for effective counseling. Understanding the client's history helps in assessing risk factors, determining appropriate interventions, and providing tailored education. It also promotes trust and open communication.
Choice B is incorrect as advising clients not to disclose their sexual history hinders the nurse's ability to provide comprehensive care and support. Choice C is incorrect because focusing only on present symptoms may overlook important information needed for proper assessment and management. Choice D is incorrect as only asking about high-risk behavior limits the scope of the assessment and may miss potential risk factors.
A nurse is caring for a client receiving TPN. What action should the nurse take?
- A. Monitor serum sodium levels daily.
- B. Check the client's capillary blood glucose level every 4 hr.
- C. Administer the solution at room temperature.
- D. Discontinue abruptly if the client reports nausea.
Correct Answer: B
Rationale: The correct answer is B: Check the client's capillary blood glucose level every 4 hr. This is crucial because TPN can cause hyperglycemia due to its high glucose content. Monitoring blood glucose levels helps in detecting and managing hyperglycemia.
Incorrect answers:
A: Monitoring serum sodium levels is not directly related to TPN administration.
C: Administering the solution at room temperature is not necessary for TPN administration.
D: Discontinuing TPN abruptly can lead to serious complications; it should be gradually tapered off.
Overall, monitoring blood glucose levels is essential in TPN therapy to prevent complications related to hyperglycemia.
A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations?
- A. Developing breast cancer
- B. Developing ovarian cancer
- C. Developing uterine cancer
- D. Developing cervical cancer
Correct Answer: A
Rationale: The correct answer is A: Developing breast cancer. The BRCA1 gene mutation is associated with an increased risk of breast cancer in women. The mutation affects the body's ability to repair damaged DNA, leading to a higher likelihood of developing breast cancer. This risk is significantly higher in women with the mutant BRCA1 gene compared to those without it. Choices B, C, and D are incorrect because the BRCA1 gene mutation is not specifically linked to an increased risk of ovarian, uterine, or cervical cancer. Therefore, the client should be counseled and monitored closely for early detection and prevention of breast cancer.
A nurse assesses a client in skeletal traction. What indicates infection at the pin sites?
- A. Pallor
- B. Fever
- C. Bradycardia
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Fever. Infection at the pin sites in skeletal traction commonly presents with systemic signs like fever. Fever is a typical response to infection as the body tries to fight off the invading pathogens. Pallor, bradycardia, and elevated blood pressure are not specific indicators of infection at pin sites. Pallor may indicate poor perfusion, bradycardia is a slow heart rate which is not typically associated with infection, and elevated blood pressure can be a response to various stressors but not a specific sign of infection at pin sites. In summary, fever is the most reliable indicator of infection at pin sites due to its systemic nature.
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
- A. Clear breath sounds on the affected side
- B. Reduction in drainage output
- C. Development of subcutaneous emphysema
- D. Minimal pain at the surgical site
Correct Answer: C
Rationale: Subcutaneous emphysema, where air gets trapped under the skin, may indicate an underlying pneumothorax and should be reported to the provider.