Nokea
A client's Salem sump tube (nasogastric).
Which of the following findings would indicate to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
- A. Fluctuation of the fluid level in the water seal chamber.
- B. Active bubbling in the suction bottle.
- C. The presence of a hissing sound from the blue lumen tube.
- D. A pressure of 25 mm Hg in the esophageal balloon.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct-'hissing' sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube
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A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
- A. Avoid brushing his teeth until the ulcers heal.
- B. Rinse his mouth frequently with normal saline.
- C. Rinse his mouth frequently with hydrogen peroxide.
- D. Cleanse his teeth and mouth with lemon and glycerin swabs.
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
An adult is admitted with deep partialthickness and full-thickness burns on both lower legs, the anterior chest, and the anterior and posterior aspects of the right arm. Using the Rule of Nines, calculate the percentage of body burned.
- A. 27%
- B. 36%
- C. 45%
- D. 63%
Correct Answer: B
Rationale: Using the Rule of Nines: both lower legs (18%), anterior chest (9%), right arm anterior and posterior (9%) = 18 + 9 + 9 = 36% total body surface area burned.
The client has recently had a colostomy. The nurse is providing home care and is teaching the client about care of his colostomy. Which comment by the client indicates understanding of the care of his colostomy?
- A. I will use hot water to irrigate the colostomy.'
- B. If my skin gets red, I will put alcohol on it.'
- C. I will irrigate the colostomy at the same time each day.'
- D. I should do the irrigation while lying in bed.'
Correct Answer: C
Rationale: Regularly timed colostomy irrigation promotes predictable bowel patterns, indicating understanding. Hot water, alcohol, or bed irrigation are incorrect.
A client experiencing hallucinations.
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
- A. The client sits immobilized for long periods of time.
- B. The client turns and tilts his head as if talking to someone.
- C. The client expresses the belief that the physician is out to get him.
- D. The client wrings his hands and paces constantly.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety
Which of the following electrolytes must be maintained in a steady state for a client receiving lithium?
- A. Sodium
- B. Potassium
- C. Chloride
- D. Magnesium
Correct Answer: A
Rationale: Sodium levels must be stable in clients taking lithium, as fluctuations can affect lithium levels and toxicity risk.