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When a client has a chest drainage system in place, where should the system be placed?
- A. above the client's head
- B. at the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct Answer: D
Rationale: A chest drainage system should be placed below the level of the client's chest so that the drainage flows out of the chest into the system. The remaining choices are too high and do not allow fluid to drain out of the chest.
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In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms
- B. nutritional status
- C. bleeding problems
- D. availability of insulin
Correct Answer: C
Rationale: Bleeding problems are not typically associated with diabetes management. Assessing diabetic symptoms, nutritional status, and insulin availability are critical to ensure glycemic control in a disaster.
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
- A. The history and presentation might indicate chickenpox, a highly contagious disease.
- B. The lesions might indicate a noncontagious infection that does not require isolation.
- C. The history and presentation might indicate an infectious illness called impetigo.
- D. The lesions are not contagious unless others have open wounds or lesions themselves.
Correct Answer: C
Rationale: The scenario describes classic impetigo for which the physician is likely to order antibiotic therapy. Chickenpox is highly contagious but presents with a history of high fever followed by a vesicular rash.
Regardless of their practice area, nurses should be concerned with:
- A. All drug-resistant bacteria
- B. Microorganisms that are critical
- C. Transmission of microorganisms
- D. Overprescription of bacteriostatic drugs
Correct Answer: C
Rationale: Preventing microorganism transmission is a universal nursing concern to protect clients, families, and staff, achieved through asepsis and infection control practices.
A client begins bleeding from the site of a previous arterial blood gas draw on the right wrist. What should the nurse do first?
- A. Check the blood count.
- B. Apply pressure to the site.
- C. Document the bleeding.
- D. Monitor the bleeding.
Correct Answer: B
Rationale: If a client begins bleeding from the site of a previous arterial blood gas draw on the right wrist, the nurse should first apply pressure to the site. This prevents further bleeding. The remaining choices can be performed later.
Which of the following indicates a hazard for a client on oxygen therapy?
- A. A No Smoking sign is on the door.
- B. The client is wearing a synthetic gown.
- C. Electrical equipment is grounded.
- D. Matches are removed.
Correct Answer: B
Rationale: A synthetic gown might generate sparks of static electricity, which can be a fire hazard, particularly in the presence of oxygen. The client on oxygen therapy should wear a cotton gown. The remaining options are appropriate safety measures.