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The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?
- A. Examine the entire system and tubing for air leaks.
- B. Lower the level of suction.
- C. Nothing; vigorous bubbling is expected
- D. Ask the patient to cough forcefully.
Correct Answer: A
Rationale: The correct answer is A. First, the nurse should assess the chest-drainage system and tubing for any air leaks. Air leaks can cause bubbling in the water-seal chamber, indicating a potential issue with the system's integrity. By examining the entire system, the nurse can identify and correct any leaks to ensure proper functioning of the chest-drainage system. Lowering the level of suction (choice B) may not address the underlying issue of air leaks. Doing nothing (choice C) is not appropriate as vigorous bubbling indicates a problem. Asking the patient to cough forcefully (choice D) is unrelated to addressing bubbling in the water-seal chamber.
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A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- A. Eversion of the right nipple and mobile
- B. Mobile mass that is soft and easily mass delineated
- C. Non-mobile mass with irregular edges
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges. A non-mobile mass with irregular edges is more likely to be cancerous as it indicates potential infiltration into surrounding tissues. This finding raises suspicion for malignancy as cancerous lumps tend to have irregular shapes due to their invasive nature. In contrast, options A and B describe characteristics of benign masses, such as mobile, soft, and easily delineated. Option D indicates no palpable lymph nodes, which does not directly correlate with the characteristics of the breast lump. Therefore, option C is the most concerning and indicative of a potentially cancerous lesion based on the assessment findings provided.
Which of the ff. would the nurse explain to the patient is the triad of symptoms associated with Meniere’s disease?
- A. Hearing loss, vertigo, and tinnitus
- B. Nausea, vomiting and pain
- C. Nystagmus, headache and vomiting
- D. Nystagmus, vomiting and pain
Correct Answer: A
Rationale: The correct answer is A: Hearing loss, vertigo, and tinnitus. Meniere's disease is characterized by a triad of symptoms: recurrent episodes of vertigo, sensorineural hearing loss, and tinnitus. Vertigo is a spinning sensation, hearing loss affects the inner ear, and tinnitus is ringing in the ear. Nausea, vomiting, pain, nystagmus, or headache are not typically part of the classic triad of Meniere's disease symptoms. Therefore, option A is the most appropriate choice based on the specific symptomatology associated with Meniere's disease.
A nurse has been caring for a client with chronic obstructive pulmonary disease (COPD). What should the nurse focus on during the evaluation phase?
- A. Documenting all interventions performed
- B. Reviewing the client’s progress toward meeting goals
- C. Delegating further care to another healthcare professional
- D. Ensuring compliance with all physician orders
Correct Answer: B
Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan.
A: Documenting interventions is important but not the primary focus during the evaluation phase.
C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan.
D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.
Which of the ff is the diagnostic sign for pericarditis?
- A. Precordial pain
- B. Pericardial friction rub
- C. Hypotension
- D. Rapid and labored respirations INFLAMMATORY
Correct Answer: B
Rationale: The correct answer is B: Pericardial friction rub. This is a key diagnostic sign of pericarditis due to the inflammation of the pericardial layers causing a rough, grating sound heard upon auscultation. Precordial pain (A) is a common symptom but not a specific diagnostic sign. Hypotension (C) and rapid/labored respirations (D) are not typically associated with pericarditis. Therefore, the presence of a pericardial friction rub is crucial in confirming the diagnosis of pericarditis.
Which of the following patients should the nurse monitors because of increased risk for surgical complications?
- A. 25-year old with appendicitis
- B. patient 5’3” in height, weight 180 lbs
- C. 12-year old with fractured knee
- D. 17-year old with gallstone
Correct Answer: B
Rationale: The correct answer is B because the patient's Body Mass Index (BMI) indicates obesity, putting them at higher risk for surgical complications. Obesity is associated with increased risks of infections, delayed wound healing, respiratory issues, and cardiovascular problems post-surgery. Monitoring this patient closely is crucial.
Choice A is less likely to have increased surgical complications due to age and condition. Choice C, a 12-year-old, is less likely to have significant surgical complications compared to adults. Choice D, a 17-year-old with gallstones, may have risks but the BMI of the patient in choice B indicates a higher risk.