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The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:
- A. For administration of oxygen.
- B. To promote formation of lung scar tissue.
- C. To insert antibiotics into the pleural space.
- D. To remove air and fluid.
Correct Answer: D
Rationale: A chest tube in pneumothorax removes air and fluid from the pleural space, restoring lung expansion. It is not used for oxygen, scar tissue, or antibiotics.
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A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate?
- A. The procedure will result in enlargement of the pyloric sphincter.
- B. The procedure will result in anastomosis of the gastric stump to the jejunum.
- C. The procedure will result in removal of the duodenum.
- D. The procedure will result in repositioning of the vagus nerve.
Correct Answer: B
Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum, bypassing the duodenum. The other options are incorrect descriptions of the procedure.
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
- A. To promote oxygen intake.
- B. To strengthen the diaphragm.
- C. To strengthen the intercostal muscles.
- D. To promote carbon dioxide elimination.
Correct Answer: D
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.
A client with acute renal failure is prescribed a low-potassium diet. Which food should be avoided?
- A. Bananas.
- B. Rice.
- C. Apples.
- D. Bread.
Correct Answer: A
Rationale: Bananas are high in potassium, unsuitable for a low-potassium diet.
The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following?
- A. Obtaining an infusion pump for the medication.
- B. Monitoring blood pressure every 4 hours.
- C. Monitoring urine output hourly.
- D. Obtaining serum potassium levels daily.
Correct Answer: A
Rationale: An infusion pump ensures accurate delivery of nitroglycerin, which requires precise titration. BP monitoring should be more frequent (e.g., every 15-30 minutes), and urine output and potassium levels are not primary concerns.
A client with an ileal conduit should report:
- A. Mucus in urine.
- B. Stoma bleeding.
- C. Yellow urine.
- D. No odor.
Correct Answer: B
Rationale: Stoma bleeding is abnormal and may indicate trauma or infection.