Nokea
What is the priority when managing a client with a chest tube postoperatively?
- A. Clamp the chest tube for 30 minutes every 4 hours
- B. Check for air leaks and proper functioning of the chest tube
- C. Encourage deep breathing and coughing every 2 hours
- D. Encourage frequent coughing to clear secretions
Correct Answer: B
Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.
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A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?
- A. The client advances the cane 18 inches in front of the foot
- B. The client holds the cane in the left hand
- C. The client advances the cane and the right leg simultaneously
- D. The client holds the cane with the elbow flexed at 60°
Correct Answer: B
Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.
A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?
- A. Increased heart rate
- B. Persistent cough
- C. Constipation
- D. Sweating
Correct Answer: B
Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.
The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?
- A. Request an occupational therapy consult to determine the need for assistive devices
- B. Assign assistive personnel to perform self-care tasks for the client
- C. Instruct the client to focus on gradually resuming self-care tasks
- D. Ask the client if a family member is available to assist with his care
Correct Answer: C
Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.
A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Position the drainage bag below the bladder
- B. Wipe the drainage port after emptying
- C. Insert the catheter using sterile technique
- D. Avoid cleansing the urinary meatus
Correct Answer: B
Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.
How should a healthcare provider educate a patient with hypertension about lifestyle modifications?
- A. Reduce sodium intake
- B. Increase physical activity
- C. Quit smoking
- D. Avoid alcohol
Correct Answer: A
Rationale: When educating a patient with hypertension about lifestyle modifications, reducing sodium intake is crucial as excess sodium can contribute to high blood pressure. While increasing physical activity is beneficial for overall health, it is not the primary lifestyle modification specifically targeted at hypertension. Quitting smoking and avoiding alcohol are important for general health but are not the first-line lifestyle modifications recommended for hypertension. Therefore, the correct answer is to reduce sodium intake.