Which tubes drain gastric contents (select all that apply)?
- A. T-tube
- B. Hemovac
- C. Nasogastric tube
- D. Indwelling catheter
Correct Answer: D
Rationale: Nasogastric and gastrointestinal tubes drain gastric contents effectively.
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Which client(s) would be best to assign to an experienced nurse in an ambulatory eye surgery center? (Choose all that apply.)
- A. A client who needs post-operative instructions for cataract surgery.
- B. A client who needs an eye-pad and a metal shield applied.
- C. A client who needs home health referral for dressing changes and eye drops.
- D. A client who needs teaching about self-administration of eye drops.
Correct Answer: A
Rationale: Clients requiring complex post-operative instructions, such as those for cataract surgery, benefit most from the expertise of an experienced nurse.
What type of shock is the client experiencing if there is no urine return after inserting a Foley catheter?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?
- A. Dyspnea
- B. Bradycardia
- C. Barrel chest
- D. Clubbing of the fingers
Correct Answer: B
Rationale: Step 1: Emphysema causes impaired gas exchange, leading to dyspnea (A) due to difficulty breathing.
Step 2: Emphysema results in hyperinflation of the lungs, causing a barrel chest (C) due to increased chest diameter.
Step 3: Clubbing of the fingers (D) is a sign of chronic hypoxia, commonly seen in emphysema.
Step 4: Bradycardia (B) is not typically associated with emphysema; tachycardia is more common due to the body compensating for hypoxia.
Which of the following charts does the nurse use to check color vision?
- A. Ishihara polychromatic plates
- B. Rosenbaum Pocket Vision Screener
- C. Snellen eye chart
- D. Jaeger chart
Correct Answer: A
Rationale: The Ishihara polychromatic plates are specifically designed to test for color blindness by using patterns of colored dots.
What would be useful in helping Mr. Jackson prepare for chest tube insertion?
- A. Explain the etiology of his condition
- B. Ask if he has any questions about the insertion procedure and its purpose
- C. Teach him to splint his chest wall
- D. Reassure him that the procedure is painless
Correct Answer: C
Rationale: Splinting minimizes movement and discomfort during the procedure.