Nokea
While caring for a client with bilateral chest tubes, the bubbling in the water-seal chamber of the right chest tube stops. What action is most important for the nurse to take?
- A. Check the chest tube connections to the water-seal container
- B. Replace the water-seal collection container
- C. Increase the amount of wall suction connected to the right chest tube
- D. Milk the tubing connected to the right chest tube
Correct Answer: A
Rationale: The most important action for the nurse to take when the bubbling in the water-seal chamber of the right chest tube stops is to check the chest tube connections to the water-seal container. This is crucial to ensure there are no disconnections or leaks affecting the bubbling. Replacing the water-seal collection container (choice B) is not necessary unless there is a malfunction; increasing suction (choice C) without assessing the connections can be harmful, and 'milking' the tubing (choice D) is an inappropriate action that can cause damage to the system.
You may also like to solve these questions
When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)
- A. 42
- B. 38
- C. 48
- D. 50
Correct Answer: A
Rationale: By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.
When a UAP reports to the charge nurse that a client has a weak pulse with a rate of 44 beats per minute, what action should the charge nurse implement?
- A. Instruct the UAP to count the client's apical pulse rate for sixty seconds.
- B. Determine if the UAP also measured the client's capillary refill time.
- C. Assign a practical nurse (LPN) to determine if an apical radial pulse deficit is present.
- D. Notify the health care provider of the abnormal pulse rate and pulse volume.
Correct Answer: D
Rationale: The correct action for the charge nurse to implement is to notify the health care provider of the abnormal pulse rate and pulse volume. A weak pulse with bradycardia (pulse rate of 44 beats per minute) requires immediate follow-up to investigate potential underlying issues. In this situation, it is crucial to involve the healthcare provider for further assessment and intervention. Instructing the UAP to count the client's apical pulse rate for sixty seconds (Choice A) may delay necessary actions. Determining capillary refill time (Choice B) is not directly related to addressing a weak pulse, and assigning an LPN to assess an apical radial pulse deficit (Choice C) is not as urgent as involving the healthcare provider.
An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today?
- A. Assist the client in identifying goals for the day
- B. Encourage the client to participate in a team sport for one hour
- C. Schedule the client for a group session that focuses on self-esteem
- D. Help the client develop a list of daily affirmations
Correct Answer: A
Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.
The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?
- A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
- B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
- C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
- D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills
Correct Answer: C
Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.
The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance?
- A. Wearing gloves when providing care to the client
- B. Encouraging the client to join a support group
- C. Shaking hands with the client during an introduction
- D. Allowing the client to express their feelings openly
Correct Answer: B
Rationale: Encouraging the client to join a support group is the best option to address the client's psychosocial need for acceptance. Support groups provide a sense of belonging, understanding, and acceptance from peers who share similar experiences. This helps the client feel accepted despite their condition. Wearing gloves when providing care, shaking hands during an introduction, and allowing the client to express feelings openly are important but do not directly address the client's need for acceptance.