Nokea
A client has a chest tube inserted for treatment of a hemothorax.
Which of the following findings would indicate to the nurse that there is a problem with the effective functioning of the chest tube?
- A. 15-cm of water is present in the suction control chamber.
- B. Constant bubbling is observed in the water seal chamber.
- C. 2-cm of water is present in the water seal chamber.
- D. Clots of blood are observed in the collection chamber.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) appropriate, regulates the amount of suction delivered to the patient (2) correct-would indicate an air leak, would not allow negative pressure to be reestablished and would hinder complete resolution of the pneumothorax (3) appropriate, provides for a water seal (4) would be an expected finding
You may also like to solve these questions
A child with celiac disease.
The nurse is instructing the parents of a child with celiac disease. The nurse knows that teaching has been effective when the parents make which of the following statements?
- A. My child's diet should include raw vegetables, fruits, and crackers.
- B. My child's diet should be high in carbohydrates, high in calories, and high in proteins.
- C. The only restriction in my child's diet should be breads and cereals.
- D. My child's diet should be high in calories, high in protein, and restrict foods containing rye, oats, wheat, and barley.
Correct Answer: D
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a correct statement. The topic of the question is unstated. (1) does not reflect appropriate dietary needs for this child (2) does not reflect appropriate dietary needs for this child (3) does not reflect appropriate dietary needs for this child (4) correct-celiac disease is characterized by an intolerance for gluten; foods containing rye, oats, wheat, and barley should be restricted
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any eye pain.
- C. Use the drops every 4 hours.
- D. Avoid regular eye exams.
Correct Answer: B
Rationale: Eye pain may indicate a complication with latanoprost, requiring reporting. Options A, C, and D are incorrect.
The nurse’s INITIAL priority when managing a physically assaultive client is to
- A. What is the initial priority when managing a physically assaultive client?
- B. Restrict the client to the room.
- C. Place the client under one-to-one supervision.
- D. Restore the client’s self-control and prevent further loss of control.
- E. Clear the immediate area of other clients to prevent harm.
Correct Answer: C
Rationale: Restoring the client’s self-control is the initial priority to ensure safety and prevent escalation. This involves assessing the situation, using psychological or chemical interventions, and possibly physical control. Room restriction, supervision, or clearing the area are secondary or impractical during rapid escalation.
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.
The licensed practical nurse is caring for a 1-year old with a history of prematurity. Which developmental finding requires further evaluation by the physician?
- A. The child has been creeping for 3 months.
- B. The child can pull to a standing position.
- C. The child uses a pincer grasp.
- D. The child can sit with support.
Correct Answer: D
Rationale: Sitting with support at 1 year is delayed, especially for a preterm child, and requires evaluation. Creeping , standing , and pincer grasp are age-appropriate.