Nokea
The physician inserted a chest tube drainage to Mr. Alda in order to help re-expand the lungs. Which of the following should you prepare FIRST as a nurse in case of emergency when the tube is accidentally disconnected?
- A. sterile clamps
- B. Sterile dressing.
- C. Another chest tube
- D. A bottle of sterile water.
Correct Answer: A
Rationale: Correct Answer: A - sterile clamps
Rationale:
1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space.
2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space.
3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection.
4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation.
Summary of other choices:
B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space.
C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube.
D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.
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A 20-year-old woman presents with sudden onset of severe lower abdominal pain and missed menstrual periods for the past two months. She has a positive urine pregnancy test. On transvaginal ultrasound, an empty uterus is visualized, and there is fluid in the cul-de-sac. Which condition is most likely to be responsible for these findings?
- A. Ovarian cyst rupture
- B. Ectopic pregnancy
- C. Septic abortion
- D. Ovarian torsion
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. In this scenario, the combination of missed periods, positive pregnancy test, and empty uterus on ultrasound with fluid in the cul-de-sac is highly suggestive of an ectopic pregnancy. Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, commonly in the fallopian tube. The presence of fluid in the cul-de-sac indicates possible blood from a ruptured ectopic pregnancy, causing the severe lower abdominal pain. Ovarian cyst rupture (A) typically presents with less severe pain. Septic abortion (C) would present with signs of infection and products of conception in the uterus. Ovarian torsion (D) would present with acute onset of unilateral lower abdominal pain and a palpable adnexal mass, not fluid in the cul-de-sac.
Nurse Chona read in one nurse's notes chart this documentation: "Refused to eat and fell from bed". Which of the following is lacking in this documentation?
- A. Time of complaint, for missed and reaction on fall incurred.
- B. Referrals made on fall medications given and reasons of falling.
- C. Contents or complaints, reasons of refusing meal and nature of fall.
- D. Time of eating, medications for back pain and intense of pain.
Correct Answer: C
Rationale: The correct answer is C because the documentation lacks essential details regarding the contents of the complaints, reasons for refusing the meal, and the nature of the fall. This information is crucial for understanding the patient's condition and providing appropriate care. Choice A is not directly related to the documentation provided. Choice B is about referrals and medications, which are not mentioned in the documentation. Choice D is about eating time and medications for pain, which are also not relevant to the documentation provided. Therefore, the correct answer is C as it addresses the specific missing information in the nurse's notes.
In providing tracheostomy care which of the following is the nurse's PRIORITY nursing action? The nurse ________.
- A. Cuts the dressing using sterile scissors
- B. Clean the incisions with iodine-based antiseptic
- C. Secures clean ties before removing soiled ones
- D. Uses clean technique
Correct Answer: C
Rationale: The correct answer is C: Secures clean ties before removing soiled ones. This is the priority action because securing clean ties prevents accidental dislodgement of the tracheostomy tube, ensuring the patient's airway remains patent. Cutting the dressing (A) or cleaning the incisions (B) can be important but not as critical as securing the tube. Using clean technique (D) is essential but not the priority in this situation.
The nurse assesses the uterine fundus of the mother. Which part of the abdomen will the nurse begin?
- A. Symphysis pubis
- B. Midline
- C. Umbilicus
- D. Sides of the abdomen
Correct Answer: C
Rationale: The correct answer is C: Umbilicus. The nurse begins assessing the uterine fundus at the level of the umbilicus as it is a standard reference point for postpartum fundal height measurement. This location allows for consistency and accuracy in tracking the descent of the uterus back into the pelvic cavity. Starting at the umbilicus also helps in monitoring the involution process and prevents potential errors in fundal height assessment.
Symphysis pubis (A) is too low and not typically used as a reference point for uterine fundal assessment. Midline (B) is vague and does not provide a specific anatomical landmark. Sides of the abdomen (D) do not give a standardized starting point for measuring the uterine fundus, leading to potential variability in assessment.
The physician prescribes decongestant intranasal spray. The nurse instructs the client on the proper use of the spray. Which of the following procedures is the CORRECT method?
- A. Finish instillation of spray into one nostril before spraying into the other nostril
- B. Inhale quickly to prevent irritation off the mucous membranes
- C. Blow the nose after spraying to prevent medications from entering the throat
- D. Tilt the head slightly forward and angle the bottle toward the side of the nostril
Correct Answer: D
Rationale: The correct answer is D: Tilt the head slightly forward and angle the bottle toward the side of the nostril. This method allows for proper administration of the spray into the nasal passage, ensuring effective delivery of the medication. Tilted head helps direct the spray towards the nasal cavity without causing discomfort or leakage. It also helps prevent the medication from dripping down the back of the throat.
Choices A, B, and C are incorrect:
A: Finishing instillation in one nostril before moving to the other can lead to uneven distribution of medication and reduced effectiveness.
B: Inhaling quickly may cause irritation and discomfort to the mucous membranes due to the forceful intake of the spray.
C: Blowing the nose after spraying can expel the medication before it has a chance to be absorbed, decreasing its efficacy.