Nokea
The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax?
- A. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures.
- B. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere.
- C. The injury allows air into the pleural space but prevents it from escaping from the pleural space.
- D. A tension pneumothorax results from a puncture of the pleura during a central line placement.
Correct Answer: C
Rationale: Tension pneumothorax traps air in the pleural space (C), increasing pressure. Bleb rupture (A) causes simple pneumothorax, free air movement (B) is open pneumothorax, and central line (D) is a cause, not definition.
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While withdrawing the suction catheter from a client's tracheostomy tube, which nursing technique is correct?
- A. Remove the catheter slowly.
- B. Push and pull the catheter.
- C. Plunge the catheter up and down.
- D. Twist and rotate the catheter.
Correct Answer: A
Rationale: Removing the catheter slowly while applying intermittent suction ensures effective secretion removal without causing trauma.
The HCP has recommended a total laryngectomy for a male client diagnosed with cancer of the larynx but the client refuses. Which intervention by the nurse illustrates the ethical principle of nonmalfeasance?
- A. The nurse listens to the client explain why he is refusing surgery.
- B. The nurse and significant other insist that the client have the surgery.
- C. The nurse refers the client to a counselor for help with the decision.
- D. The nurse asks a cancer survivor to come and discuss the surgery with the client.
Correct Answer: A
Rationale: Listening to the client’s reasons (A) respects autonomy and avoids harm (nonmalfeasance). Insisting (B), counseling (C), and survivor talks (D) may pressure or influence unduly.
Which specimen collection technique should the nurse use to correctly obtain the throat culture from the client?
- A. The nurse asks the client to expectorate sputum into a paper cup.
- B. The nurse wipes the inner mouth and tongue with gauze.
- C. The nurse swabs the throat with a sterile cotton applicator.
- D. The nurse collects saliva in a sterile culture cup.
Correct Answer: C
Rationale: A throat culture requires swabbing the pharynx with a sterile cotton applicator to collect a sample from the area most likely to harbor pathogens.
The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription?
- A. These pills will make me feel better fast and I can return to work.
- B. The antibiotics will help prevent me from developing a bacterial pneumonia.
- C. If I had gotten this prescription sooner, I could have prevented this illness.
- D. I need to take these pills until I feel better; then I can stop taking the rest.
Correct Answer: B
Rationale: Antibiotics for influenza (B) prevent secondary bacterial pneumonia, not treat the virus. Quick recovery (A), prevention (C), and stopping early (D) are incorrect.
What information does the nurse need to know first before recommending further action?
- A. What is the victim's age?
- B. Can the victim cough?
- C. How is the victim positioned?
- D. Can the victim still swallow?
Correct Answer: B
Rationale: Determining if the victim can cough assesses whether the airway is partially or completely obstructed, guiding the next steps.