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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A 35-year-old client is admitted for elective tubal ligation. During the preoperative teaching, the client states, 'The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?' The best explanation by the nurse is that balanced anesthesia:
- A. is a type of regional anesthesia.
- B. uses equal amounts of inhalation agents and liquid agents.
- C. does not depress the central nervous system.
- D. is a combination of several anesthetic agents or drugs, which produce a smooth induction with minimal complications.
Correct Answer: D
Rationale: A regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. Varying amounts of anesthetic agents are used when employing balanced anesthesia. The amounts used depend on the age, weight, condition of the client and the surgical procedure. General anesthesia is a drug induced depression of the central nervous system, which produces loss of consciousness and decreased muscle activity. Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.
After administering injections of penicillin, the nurse should ask the client to wait at least __ minutes before allowing the client to leave the healthcare facility.
- A. 12
- B. 15
- C. 5
- D. 30
Correct Answer: B
Rationale: The rationale is that waiting 15 minutes allows time to observe for any adverse reactions to the medication.
A nursing department in an acute care setting decides to redesign its nursing practice based on a theoretical framework. The feedback from patients, families, and staff reflects that caring is a key element. Which theorist best supports this concept?
- A. Erikson.
- B. Maslow.
- C. Rogers.
- D. Watson.
Correct Answer: D
Rationale: Jean Watson's theory emphasizes the importance of caring in nursing.
Which quality of care measures influence the payment for health care services by third-party payers (select all that apply)?
- A. Clinical outcomes
- B. Regulatory agencies
- C. Use of evidence-based practice
- D. Occurrence of preventable conditions
Correct Answer: A
Rationale: Third-party payers prioritize clinical outcomes, evidence-based practice adoption, and minimizing preventable conditions to ensure value-based care.
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.
A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.