Nokea
The nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse should include which interventions in the plan? Select all that apply.
- A. Changing the client's position often
- B. Clamping the chest tube intermittently
- C. Maintaining the collection chamber below the client's waist
- D. Adding water to the suction control chamber as it evaporates
- E. Taping the connection between the chest tube and the drainage system
Correct Answer: A,C,D,E
Rationale: Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy.
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A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
A child hospitalized with a diagnosis of lead poisoning is prescribed chelation therapy. The nurse caring for the child should prepare to administer which medication?
- A. Ipecac syrup
- B. Activated charcoal
- C. Sodium bicarbonate
- D. Calcium disodium edetate (EDTA)
Correct Answer: D
Rationale: EDTA is a chelating agent that is used to treat lead poisoning. Ipecac syrup may be prescribed by the primary health care provider for use in the hospital setting but would not be used to treat lead poisoning. Activated charcoal is used to decrease absorption in certain poisoning situations. Sodium bicarbonate may be used in salicylate poisoning.
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
- A. Abnormal involuntary flexion of the extremities
- B. Abnormal involuntary extension of the extremities
- C. Upper extremity extension with lower extremity flexion
- D. Upper extremity flexion with lower extremity extension
Correct Answer: B
Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.
In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.
The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population?
- A. 90 beats per minute
- B. 140 beats per minute
- C. 180 beats per minute
- D. 190 beats per minute
Correct Answer: B
Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Options 1, 3, and 4 are incorrect. Option 1 indicates bradycardia, and options 3 and 4 indicate tachycardia (greater than 100 beats per minute).