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When caring for a client with a chest tube and water-seal drainage system, the nurse should:
- A. Verify that the air vent on the water-seal drainage system is capped when the suction is off.
- B. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs.
- C. Ensure that the chest tube is clamped when moving the client out of the bed.
- D. Make sure that the drainage apparatus is always below the client's chest level.
Correct Answer: D
Rationale: Keeping the drainage apparatus below chest level prevents fluid backflow into the pleural space. Capping the vent, stripping tubes, or clamping during movement risks complications like pneumothorax.
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Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome?
- A. The client maintains bed rest.
- B. There is redness and swelling at the aspiration site.
- C. The client requests morphine sulfate for pain.
- D. There is no bleeding at the aspiration site.
Correct Answer: D
Rationale: A successful outcome 24 hours after bone marrow aspiration is no bleeding at the site, indicating proper healing and no complications. Bed rest is not required, redness/swelling suggests infection, and morphine requests indicate uncontrolled pain, which is not expected.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
- A. Treating the underlying cause.
- B. Administering heparin.
- C. Administering warfarin sodium (Coumadin).
- D. Replacing depleted blood products.
Correct Answer: C
Rationale: Warfarin is contraindicated in DIC because it further inhibits clotting factors, worsening bleeding. Treating the underlying cause, administering heparin (to stop clotting), and replacing blood products are standard treatments to manage DIC.
Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
- A. Imbalanced nutrition: Less than body requirements.
- B. Ineffective health maintenance related to ineffective coping skills.
- C. Acute pain.
- D. Activity intolerance.
Correct Answer: A
Rationale: Nausea and vomiting from illness can lead to inadequate food intake, causing imbalanced nutrition, a priority due to the risk of hypoglycemia or ketoacidosis.
A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:
- A. Pulse rate is normal.
- B. Pupils are reacting to light.
- C. Mucous membranes are pink.
- D. Systolic blood pressure is at least 80 mm Hg.
Correct Answer: D
Rationale: A systolic blood pressure of at least 80 mm Hg indicates effective CPR, as it reflects adequate circulation and perfusion.