Nokea
What condition can develop if Mr. Taylor’s chest tube is accidentally pulled out?
- A. Tension pneumothorax
- B. Open pneumothorax
- C. Hemopneumothorax
- D. Paradoxic respirations
Correct Answer: B
Rationale: An open pneumothorax occurs when air enters the pleural space through an external opening.
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A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
- A. Attending a class on tracheostomy care
- B. Verbally explaining all steps in the procedure
- C. Performing the procedure independently
- D. Asking relevant questions about suctioning
Correct Answer: C
Rationale: The correct answer is C: Performing the procedure independently. This indicates readiness for discharge as it demonstrates the partner's ability to safely and effectively perform suctioning without direct supervision. Attending a class (A) and asking relevant questions (D) are important but do not necessarily indicate competence in performing the procedure. Verbally explaining the steps (B) shows understanding but does not confirm practical skill.
While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct Answer: A
Rationale: The correct answer is A: Airway obstruction. This should be prioritized because burns to the head, neck, and chest can lead to swelling and inflammation, potentially compromising the airway. Maintaining a clear airway is crucial for oxygenation and ventilation. If the airway becomes obstructed, it can quickly lead to respiratory distress or failure. Assessing for signs of airway compromise and intervening promptly is essential to prevent serious complications.
Choices B, C, and D are incorrect because while infection, fluid imbalance, and paralytic ileus are also important considerations in burn care, they are not as immediately life-threatening as airway obstruction in this case. Infection can be managed with appropriate wound care, fluid imbalance can be addressed with fluid resuscitation, and paralytic ileus can be treated with medications and bowel management strategies.
Match the descriptions to the stages of sleep. Some descriptions may have more than one stage and some stages may be used more than once.
- A. Brain waves resemble wakefulness
- B. Deepest sleep, lasting 20 to 40 minutes
- C. Associated with specific EEG waveforms
- D. Most vivid dreaming occurs
Correct Answer: D
Rationale: The correct answer is D (REM). REM sleep is characterized by brain waves resembling wakefulness and vivid dreaming. The deepest sleep (B) corresponds to NREM Stage 3, while specific EEG waveforms (C) are associated with all stages.
A break in sterile technique occurs during surgery when the scrub nurse touches
- A. the mask with sterile gloved hands.
- B. sterile gloved hands to the gown at chest level.
- C. the drape at the incision site with sterile gloved hands.
- D. the lower arm to the instruments on the instrument tray.
Correct Answer: A
Rationale: Touching non-sterile items like masks compromises sterility and requires corrective action.
During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to
- A. continue the hourly neurologic assessments.
- B. inform the neurosurgeon of the patient's status.
- C. prepare the patient for emergency surgery.
- D. recheck the patient's neurologic status in 15 minutes.
Correct Answer: B
Rationale: Neurological changes could indicate worsening intracranial pressure, necessitating immediate physician notification.