Nokea
Which of the following should be readily available at the bedside of a client with a chest tube in place?
- A. A tracheostomy tray.
- B. Another sterile chest tube.
- C. A bottle of sterile water.
- D. A spirometer.
Correct Answer: C
Rationale: A bottle of sterile water is needed to restore the water seal if the chamber is compromised. Tracheostomy trays, extra chest tubes, and spirometers are not immediately necessary.
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A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.
A client has acute arterial occlusion. The physician has ordered a thrombolytic agent. Before starting the medication, the nurse should:
- A. Review the blood coagulation laboratory values
- B. Test the client's stools for occult blood
- C. Count the client's apical pulse for 1 minute
- D. Check the 24-hour urine output record
Correct Answer: A
Rationale: Before administering a thrombolytic agent for acute arterial occlusion, the nurse must review coagulation lab values (e.g., aPTT, INR, platelets) to assess bleeding risk, as thrombolytics increase hemorrhage potential. Stool testing, pulse counting, and urine output are secondary or unrelated.
A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in his car, and a drug overdose is suspected. Which of the following medications should the nurse have available for further emergency treatment?
- A. Vitamin K.
- B. Dextrose 50%.
- C. Activated charcoal powder.
- D. Sodium thiosulfate.
Correct Answer: C
Rationale: Activated charcoal is used to adsorb aspirin in the stomach, reducing absorption in an overdose. Vitamin K is for anticoagulant reversal, dextrose for hypoglycemia, and sodium thiosulfate for cyanide poisoning.
A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding of the cause of hearing loss in older adults is related to:
- A. Accumulation of cerumen in the external canal.
- B. Accumulation of cerumen in the internal canal.
- C. External otitis.
- D. Exostosis.
Correct Answer: A
Rationale: Accumulation of cerumen in the external canal is a common cause of conductive hearing loss in older adults, leading to a sensation of fullness and reduced hearing.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.