Nokea
What additional assessment should be made if there is no fluid in Mr. Jones’ chest tubes?
- A. Turn Mr. Jones on his left side and observe for drainage
- B. Clamp the chest tubes and observe Mr. Jones’ breathing pattern
- C. Auscultate for equal breath sounds bilaterally
- D. Monitor vital signs closely for hypotension, tachycardia
Correct Answer: C
Rationale: Equal breath sounds indicate proper lung expansion and functioning.
You may also like to solve these questions
When preparing a client for transfer to the ICU for placement of a pulmonary artery catheter, the nurse should explain that this catheter is used to monitor which of the following conditions?
- A. Intracranial pressure
- B. Spinal cord perfusion
- C. Renal function
- D. Hemodynamic status
Correct Answer: D
Rationale: The correct answer is D: Hemodynamic status. A pulmonary artery catheter is used to monitor hemodynamic parameters such as cardiac output, pulmonary artery pressure, and central venous pressure. This helps assess the patient's circulatory status and guide interventions in critically ill patients.
Explanation:
1. Pulmonary artery catheter measures cardiac output and helps in assessing the heart's ability to pump blood effectively.
2. It provides information on pulmonary artery pressure which reflects the pressure in the right side of the heart and pulmonary circulation.
3. Central venous pressure is also monitored, indicating the fluid status and right heart function.
Summary:
A: Intracranial pressure - Incorrect. Pulmonary artery catheter does not monitor intracranial pressure.
B: Spinal cord perfusion - Incorrect. Pulmonary artery catheter does not monitor spinal cord perfusion.
C: Renal function - Incorrect. Pulmonary artery catheter does not monitor renal function.
For Mrs. Allen's weight reduction program to be successful, what should the nurse explain?
- A. An anorexiant should be used 4-6 weeks at the beginning
- B. An intestinal bypass is recommended if rapid weight loss is not achieved
- C. Personal eating habits must be assessed objectively
- D. Complete fasting for a week is necessary
Correct Answer: C
Rationale: Assessing personal eating habits objectively helps identify areas for improvement and fosters sustainable lifestyle changes.
14. A patient newly diagnosed with type 2 diabetes has been given a prescription to start on an oral hypoglycemic. The patient tells the nurse she would rather control her blood sugar with herbal therapy. Which action should the nurse take?
- A. Advise the patient to discuss using herbal therapy with her physician.
- B. Advise the patient that herbal therapy is not safe and should not be used.
- C. Advise the patient to give the prescriptive medication time to work before using herbal therapy.
- D. Advise the patient that if she takes herbal therapy, she will have to monitor her blood sugar more often.
Correct Answer: A
Rationale: Referring the patient to her physician (option A) ensures that any decision regarding herbal therapy is made collaboratively and safely.
In what patient situations would a comprehensive assessment be performed (select all that apply)?
- A. Complaints of chest pain
- B. On initial admission to the telemetry unit
- C. On initial evaluation by the home health nurse
- D. The patient is found lying on the floor and is unresponsive
Correct Answer: B
Rationale: The correct answers are 'On initial admission to the telemetry unit,' 'On initial evaluation by the home health nurse,' and 'On arrival in the surgery holding area of the operating room.' Comprehensive assessments are necessary for baseline data collection in new or complex cases.
A clinical polysomnography (PSG) may be performed on a patient with signs and symptoms of a sleep disorder. What measures and observations does this study include (select all that apply)?
- A. Heart rate monitoring
- B. Noninvasive oxygen saturation (SpO2)
- C. Surface body temperature fluctuations
- D. Blood pressure monitoring (noninvasive)
Correct Answer: A
Rationale: The correct answers are A, B, E, F, G, H, and I. PSG includes heart rate, SpO2, airflow, muscle tone, respiratory effort, eye movements, and brain activity. Surface body temperature (C) and actigraphy (J) are not typically part of PSG.