Nokea
While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?
- A. Apply a pressure dressing around the chest tube site.
- B. Administer an oral antihistamine.
- C. Assess for allergies to topical cleaning agents.
- D. Measure the area of swelling and crackling.
Correct Answer: D
Rationale: When a nurse observes crepitus around a chest tube site, it could indicate subcutaneous emphysema, a potentially serious condition where air gets trapped under the skin. Measuring the area of swelling and crackling is important as it helps monitor the progression of subcutaneous emphysema. Applying a pressure dressing (choice A) might not address the underlying cause and could potentially worsen the condition. Administering an oral antihistamine (choice B) is not indicated for crepitus at a chest tube site. Assessing for allergies to topical cleaning agents (choice C) is important but not the immediate priority when crepitus is observed.
You may also like to solve these questions
A client is diagnosed with tuberculosis and is placed on isoniazid (INH) and rifampin (Rifadin). The nurse should emphasize the importance of
- A. Daily use of a bronchodilator
- B. The importance of taking medication as prescribed
- C. Decreasing salt intake
- D. Avoidance of direct sunlight
Correct Answer: B
Rationale: The correct answer is B: The importance of taking medication as prescribed. In the treatment of tuberculosis, adherence to the prescribed medication regimen is crucial to effectively manage the infection and prevent the development of drug resistance. Choices A, C, and D are incorrect because bronchodilators, salt intake, and sunlight exposure are not directly related to the treatment of tuberculosis with isoniazid and rifampin.
A male client with heart failure becomes short of breath, anxious, and has pink frothy sputum. What is the first action the nurse should take?
- A. Consult the charge nurse about administering morphine.
- B. Administer the morphine sulfate as prescribed.
- C. Withhold the morphine until the dyspnea resolves.
- D. Review the need for the morphine prescription with the provider.
Correct Answer: B
Rationale: The correct answer is B: Administer the morphine sulfate as prescribed. In this situation, the client is experiencing symptoms of acute pulmonary edema, a complication of heart failure. Morphine is indicated as it helps reduce anxiety and respiratory distress by decreasing preload and afterload. It dilates blood vessels, reducing the workload of the heart and improving oxygenation. The priority is to administer the morphine promptly to alleviate the client's distress and improve oxygenation. Consulting the charge nurse (A) or reviewing the need for the morphine prescription with the provider (D) would cause a delay in providing essential treatment. Withholding the morphine (C) would not be appropriate as it is indicated for this condition.
An adolescent client with intellectual disability refuses oral hygiene. A behavior modification program is recommended. Which reinforcement is best for the nurse to implement?
- A. Candy for successful oral hygiene tasks.
- B. Tokens for each successful oral hygiene task.
- C. Privilege restrictions for refusing oral hygiene tasks.
- D. Preferred activities or privileges for compliance.
Correct Answer: D
Rationale: In this scenario, the best reinforcement for the nurse to implement is preferred activities or privileges for compliance. Positive reinforcement with privileges is effective in encouraging behavior change in adolescents, including those with intellectual disabilities. Choice A (Candy for successful oral hygiene tasks) may not be suitable as it involves providing a sugary reward, which contradicts the goal of oral hygiene. Choice B (Tokens for each successful oral hygiene task) could be effective but may not be as motivating as preferred activities or privileges. Choice C (Privilege restrictions for refusing oral hygiene tasks) focuses on negative reinforcement, which is not as effective as positive reinforcement in behavior modification.
An unlicensed assistive personnel (UAP), who usually works on a surgical unit, is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units have you worked on?
- B. What type of care do you provide on the surgical unit, and what are the ages of the clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The most appropriate question by the charge nurse would be to ask the UAP if they have reviewed the list of expected skills needed on the pediatric unit. This ensures that the UAP is aware of the specific skills required for safe and appropriate care in that particular unit. Choices A, B, and C do not directly address the need for the UAP to review the expected skills, which is crucial for delegation decisions during floating assignments.
The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?
- A. Short half-life
- B. High therapeutic index
- C. Highly protein-bound
- D. Low bioavailability
Correct Answer: C
Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.