The nurse is involved in preoperative teaching with a client...

The nurse is involved in preoperative teaching with a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that the purpose of the nurse is to:

A. Prevent clots.
B. Remove air.
C. Remove fluid.
D. Facilitate 'milking' of the tubes.

Correct Answer: B, C

Rationale: Chest tubes are placed to remove air (pneumothorax) and fluid (hemothorax or pleural effusion) from the pleural space to restore negative pressure and lung expansion. Preventing clots or milking tubes is not their primary purpose.

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The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.

A. Normal blood pressure.
B. Generalized edema.
C. Normal serum lipid levels.
D. No red blood cells in the urine.
E. Elevated streptococcal antibody titers.

Correct Answer: B,D

Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.

You are the chair person for the healthcare facility's newly formed multidisciplinary Safety Committee. During the Forming stage of this group's development major conflicts have arisen. Which technique of conflict resolution should you use to resolve these conflicts?

A. Passivity
B. Compromise
C. Competition
D. Accommodating Others

Correct Answer: B

Rationale: During the Forming stage, where group members are establishing relationships, compromise is the most effective conflict resolution technique to promote collaboration and consensus while addressing conflicts constructively.

Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.

A. Have the client state his or her name.
B. Check the name on the arm band with the name on the medication.
C. Learn to recognize the client.
D. Check the client's room number.
E. Compare the date of birth on the client's chart to the date of birth on the client's armband.

Correct Answer: A,B,E

Rationale: Using two identifiers, such as the client's name, armband, and date of birth, ensures accurate medication administration. Room number and visual recognition are not reliable.

The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?

A. Implementing relaxation exercises.
B. Administering a sedative as needed.
C. Administering prophylactic antacids or histamine-2 receptor antagonists.
D. Monitoring the client's nutritional status closely.

Correct Answer: C

Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.

A client with chronic kidney disease is on a fluid restriction. How should the nurse calculate the client's daily fluid intake?

A. Based on urine output plus 500 mL
B. 1,000 mL regardless of weight
C. 20 mL/kg of body weight
D. Unlimited unless edema is present

Correct Answer: A

Rationale: Fluid intake in chronic kidney disease is typically calculated as urine output plus 500 mL to replace insensible losses while preventing fluid overload.