Nokea
While changing a client's chest tube dressing, the nurse notes a crackling 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 insertion site
- B. Assess the client for allergies to topical cleaning agents
- C. Measure the area of swelling and crackling
- D. Administer an oral antihistamine per PRN protocol
Correct Answer: A
Rationale: A crackling sensation indicates subcutaneous emphysema, caused by air trapped under the skin. Applying a pressure dressing around the chest tube insertion site can help manage the issue by preventing further air leakage into the tissues. Choice B is incorrect because the crackling sensation is not related to allergies. Choice C is incorrect as measuring the area does not address the underlying cause. Choice D is incorrect as administering an oral antihistamine is not indicated for subcutaneous emphysema.
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The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?
- A. Low-grade fever
- B. Bruising of the skin
- C. Abdominal cramping
- D. Bloody emesis
Correct Answer: D
Rationale: The correct answer is D: Bloody emesis. Bloody emesis indicates potential bleeding or severe irritation, which should be reported immediately. In the context of acute gastritis, bloody emesis could indicate a more serious complication that requires urgent medical attention. Choices A, B, and C are not typically associated with acute gastritis caused by contaminated water and do not signal as critical of a condition as bloody emesis. Low-grade fever, bruising of the skin, and abdominal cramping are more commonly associated with other conditions or may be less urgent in this context.
When taking a health history of a client admitted with acute pancreatitis, which client complaint should be expected?
- A. A low-grade fever and left lower abdominal pain
- B. Severe headache and sweating all the time
- C. Severe mid-epigastric pain after ingesting a heavy meal
- D. Dull, continuous, right lower quadrant pain and nausea
Correct Answer: C
Rationale: The correct answer is C: 'Severe mid-epigastric pain after ingesting a heavy meal.' This symptom is characteristic of acute pancreatitis due to inflammation of the pancreas, which often presents with severe pain in the mid-epigastric region that may worsen after eating. Choices A, B, and D describe symptoms that are not typically associated with acute pancreatitis. A low-grade fever and left lower abdominal pain (Choice A) may be more indicative of other conditions like diverticulitis. Severe headache and sweating (Choice B) are commonly seen in conditions like migraines or infections. Dull, continuous, right lower quadrant pain and nausea (Choice D) could be suggestive of appendicitis rather than acute pancreatitis.
The client who had a below-the-knee (BKA) amputation is being prepared for discharge to home. Which recommendation should the nurse provide this client?
- A. Inspect skin for redness
- B. Use a residual limb shrinker
- C. Apply alcohol to the stump after bathing
- D. Wash the stump with soap and water
Correct Answer: D
Rationale: The correct recommendation for a client with a below-the-knee amputation preparing for discharge is to wash the stump with soap and water. This helps maintain cleanliness and prevent infection. Inspecting the skin for redness is important to monitor for signs of infection, but it is not a specific recommendation for a BKA amputation. Using a residual limb shrinker can aid in shaping and reducing swelling in the residual limb but is not usually done immediately after a BKA amputation. Applying alcohol to the stump after bathing is not recommended as it can lead to skin irritation and dryness.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
- A. Call the radiology department
- B. Reinsert the implant into the vagina
- C. Apply double gloves to retrieve the implant for disposal
- D. Place the implant in a lead container using long-handled forceps
Correct Answer: D
Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.
Identify the placement of the stapes footplate into the bony labyrinth.
- A. Fenestra vestibuli
- B. Fenestra cochleae
- C. Tympanic membrane
- D. Round window
Correct Answer: A
Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.