Nokea
The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. This observation should prompt the nurse to do which of the following?
- A. Continue monitoring as usual; this is expected.
- B. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle.
- C. Decrease the suction to -15 cm H2O and continue observing the system for changes in bubbling during the next several hours.
- D. Drain half of the water from the water-seal chamber.
Correct Answer: B
Rationale: Constant gentle bubbling in the water-seal column suggests an air leak; checking connectors identifies the source. Expected bubbling is intermittent. Adjusting suction or draining water is inappropriate.
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The nurse is assessing a client with Buerger's disease. The nurse should determine if the client is experiencing:
- A. Thickening of the intima and media of the artery
- B. Inflammation and fibrosis of arteries, veins, and nerves
- C. Vasospasm lasting several minutes
- D. Pain, pallor, and pulselessness
Correct Answer: B
Rationale: Buerger's disease is characterized by inflammation and fibrosis of arteries, veins, and nerves, leading to occlusion and ischemia. This distinguishes it from atherosclerosis (intimal thickening), Raynaud's (vasospasm), or acute arterial occlusion (pain, pallor, pulselessness).
A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery?
- A. You cannot eat or drink anything for 24 hours.
- B. You may resume your normal diet the day after your surgery.
- C. Drink liquids today and eat lightly for a few days.
- D. You can progress from a liquid to a bland diet as tolerated.
Correct Answer: C
Rationale: Post-laparoscopic cholecystectomy, patients typically start with clear liquids and progress to light meals to avoid gastrointestinal stress. Option C is most appropriate. Option A is too restrictive, B is premature, and D is less specific.
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
- A. Placing the client on the back with a small pillow under the head.
- B. Keeping portable suctioning equipment at the bedside.
- C. Opening the client's mouth with a padded tongue blade.
- D. Cleaning the client's mouth and teeth with a toothbrush.
Correct Answer: A
Rationale: Placing the client on their back increases the risk of aspiration, especially in stroke patients with impaired swallowing. Suction equipment, padded tongue blades, and toothbrushing are appropriate for safe oral hygiene.
Galactorrhea is caused by overproduction of which hormone?
- A. Prolactin.
- B. Adrenocorticotropic hormone (ACTH).
- C. Growth hormone (GH).
- D. Thyroid-stimulating hormone (TSH).
Correct Answer: A
Rationale: Galactorrhea (inappropriate breast milk production) is caused by excess prolactin, often due to a prolactin-secreting pituitary adenoma.
The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply.
- A. Nausea and vomiting
- B. Constipation
- C. Pruritus
- D. Urinary retention
- E. Nystagmus
Correct Answer: A,B,C,D
Rationale: Fentanyl, an opioid, commonly causes nausea, constipation, pruritus, and urinary retention. Nystagmus is not a typical side effect.