Nokea
What observation would indicate the water-seal drainage system is working correctly?
- A. No bubbling of air in the suction control bottle
- B. Fluctuation of the fluid level in the tube of the water-seal bottle
- C. 25 ml of serosanguineous fluid has collected in the drainage bottle
- D. Excessive bubbling in the water-seal bottle
Correct Answer: B
Rationale: Fluctuation indicates proper lung expansion and absence of leaks.
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In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches.
- B. Green drainage.
- C. Reddened tissue.
- D. Eschar development.
Correct Answer: C
Rationale: Reddened tissue indicates healthy granulation tissue.
What is your priority intervention for this patient?
- A. Transportation arrangements to a safe house
- B. Referral to a counselor
- C. Advise about contacting the police
- D. Follow-up appointment for injuries
Correct Answer: A
Rationale: Ensuring the patient's safety by arranging transportation to a safe house is the top priority.
Which type of agent does sulfur mustard fall under?
- A. Nerve agents
- B. Blistering agents
- C. Respiratory toxins
- D. Cyanide poisonings
Correct Answer: B
Rationale: The correct answer is B because sulfur mustard is a blistering agent that causes skin and respiratory damage.
When assessing the health beliefs and practices of an older Hispanic adult, the nurse observes that the client uses a traditional folk healer to manage health problems. How would you respond?
- A. Respectfully acknowledge the practice and integrate it where possible.
- B. Discredit the folk healer's methods.
- C. Insist on conventional medical treatment only.
- D. Ignore the client's preference.
Correct Answer: A
Rationale: Respecting and integrating traditional practices fosters trust and collaboration in care delivery.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct Answer: B
Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present.
A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue.
C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress.
D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.