Nokea
Which of the following would have the highest priority in septic shock?
- A. Monitoring temperature.
- B. Monitoring pupillary reaction.
- C. Monitoring airway, breathing, circulation (ABC).
- D. Monitoring ANA and RF levels.
Correct Answer: C
Rationale: Maintaining ABCs is critical in septic shock.
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A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?
- A. Chest tube eyelets not visible
- B. Continuous bubbling in the suction control chamber
- C. Presence of tidal fluctuation in the water seal chamber
- D. Development of subcutaneous emphysema
Correct Answer: D
Rationale: The correct answer is D: Development of subcutaneous emphysema. This finding indicates air leakage, which can lead to potential complications like tension pneumothorax. Subcutaneous emphysema is a serious concern that requires immediate intervention.
A: Chest tube eyelets not visible - This is not a concerning finding as long as the chest tube is properly secured and functioning.
B: Continuous bubbling in the suction control chamber - This can indicate proper functioning of the system.
C: Presence of tidal fluctuation in the water seal chamber - This indicates that the system is working correctly, with the water seal chamber fluctuating with the patient's breathing.
Steve, who is diagnosed with pneumonia following recent intrathoracic surgery, will likely be prescribed
- A. Cephalosporin, such as cefazolin.
- B. Penicillin, such as amoxicillin.
- C. Fluoroquinolone, such as levofloxacin.
- D. Tetracycline, such as doxycycline.
Correct Answer: A
Rationale: Cephalosporins are commonly used antibiotics for treating post-surgical pneumonia.
What are the recommendations that can help develop culturally sensitive nursing care?
- A. Learn about different cultures,avoid stereotypes and involve clients in decision-making.
- B. Focus solely on universal care standards.
- C. Ignore cultural differences.
- D. All of the above.
Correct Answer: A
Rationale: Understanding cultural nuances and involving clients in care decisions enhances cultural competence and improves outcomes.
A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
- A. Continue to monitor the client.
- B. Immediately notify the healthcare provider.
- C. Reposition the client to the left side.
- D. Clamp the chest tube near the water seal.
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client. When the water seal chamber rises with client inspiration, it indicates normal functioning of the chest tube system, allowing air to exit the pleural space. Monitoring ensures proper chest tube function. Option B is incorrect because there is no indication of immediate need for healthcare provider notification. Option C is unnecessary as repositioning won't address the issue. Option D is incorrect and dangerous as clamping the chest tube can lead to tension pneumothorax.
On assessing Mr. Puff, what would you expect to find?
- A. ‘Blue bloater’ appearance
- B. Copious amount of thin sputum
- C. Increased anteroposterior chest diameter
- D. Prolonged inspiratory time
Correct Answer: C
Rationale: The correct answer is C: Increased anteroposterior chest diameter. In patients with chronic obstructive pulmonary disease (COPD), like Mr. Puff, there is often air trapping leading to hyperinflation of the lungs. This results in an increased anteroposterior chest diameter, known as a "barrel chest" appearance. Option A (‘Blue bloater’ appearance) is associated with chronic bronchitis, not necessarily COPD. Option B (Copious amount of thin sputum) is more indicative of bronchiectasis. Option D (Prolonged inspiratory time) is a nonspecific finding and not typically associated with COPD.