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The nurse is giving an end-of-shift report when a client with a chest tube is noted in the hallway with the tube disconnected. What is the most appropriate action?
- A. Clamp the chest tube immediately
- B. Put the end of the chest tube into a cup of sterile normal saline
- C. Assist the client back to the room and place him on his left side
- D. Reconnect the chest tube to the chest tube system
Correct Answer: B
Rationale: A disconnected chest tube risks air entering the pleural space, causing pneumothorax. Placing the end in sterile saline creates a water seal, preventing air entry until reconnection.
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The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
- A. Allow the client to keep the plant
- B. Place the plant by the window
- C. Water the plant for the client
- D. Tell the family members to take the plant home
Correct Answer: D
Rationale: A low WBC (neutropenia) increases infection risk, so the plant, which may harbor bacteria or fungi, should be removed.
The nurse who is caring for a client with cancer notes a WBC of 500 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every 4 hours because of risk for hypothermia
- B. Instruct the client to avoid large crowds and people who are sick
- C. Instruct in the use of a soft toothbrush
- D. Assess for hematuria
Correct Answer: B
Rationale: A WBC of 500 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people is critical to prevent infections. The other interventions are less specific.
A nurse is at a local swimming pool, and a man collapses with a cardiac arrest after exiting the pool. The man is still wet when the nurse begins cardiopulmonary resuscitation (CPR), and another person brings the automated external defibrillator (AED). Which of the following should the nurse do next?
- A. Apply the AED pads and deliver a shock.
- B. Wipe the chest dry with an available cloth or towel.
- C. Continue CPR because a client who is wet cannot receive a shock.
- D. Wipe the chest with an alcohol hand wipe to speed the evaporation of the water.
Correct Answer: B
Rationale: Wiping the chest dry (B) ensures AED pads adhere properly and deliver an effective shock. Applying pads on a wet chest (A) risks ineffective defibrillation, continuing CPR (C) delays defibrillation, and alcohol wipes (D) are inappropriate.
A 46-year-old male has been placed under therapeutic hypothermic care after a myocardial infarction (MI). The nurse correctly explains to the family,
- A. Therapeutic hypothermia increases the production of neurotransmitters in the brain.'
- B. Therapeutic hypothermia will repair damaged cardiac tissue.'
- C. Therapeutic hypothermia will help protect the brain from injury by slowing metabolism.'
- D. Therapeutic hypothermia will slow the heart rate to reduce likelihood of another MI.'
Correct Answer: C
Rationale: Therapeutic hypothermia post-MI slows metabolism, reducing cerebral oxygen demand and protecting the brain from ischemic injury.
The nurse answers a call to the unit, which turns out to be a bomb threat. Which actions by the nurse are correct? Select all that apply.
- A. dismiss the call as a prank
- B. follow facility protocol to ensure client and staff safety
- C. try to find out where the bomb is and when it will go off
- D. alert the charge nurse, security, and the police department
- E. start evacuating clients, starting with those who are most mobile first
Correct Answer: B, D
Rationale: Following protocol and alerting authorities ensure safety and proper response, while dismissing the threat or evacuating without orders is unsafe.