MODULE 9 EXAM
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? "It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't." "I ate breakfast this morning." "I didn't take my anticonvulsant today." "I didn't shampoo my hair."
"I didn't shampoo my hair" Rationale: Pre-procedure care for EEG involves client teaching about the procedure, ensuring that the client's hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.
A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? 8 mcg/mL (32 µmol/L) 3 mcg/mL (12 µmol/L) 16 mcg/mL (63 µmol/L) 28 mcg/mL (111 µmol/L)
16 mcg/mL Rationale: The therapeutic serum phenytoin range is 10 to 20 mcg/mL (40 to 79 µmol/L). If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.
A client's baseline vital signs are temperature 98°F (36.7°C) oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103°F (39.4°C). Which respiratory rate would the nurse anticipate as part of the body's response to the change in client status? 16 breaths/min 22 breaths/min 12 breaths/min 18 breaths/min
22 breaths/min Rationale: Increases in body temperature cause a corresponding increase in respiratory rate because the metabolic needs of the body increase with fever, necessitating more oxygen. The client who has a decrease in body temperature will experience a decrease in respiratory rate.
Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the primary health care provider's prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? 6 L/min 4 L/min 3 L/min 1 L/min
3 L/min Rationale: Because the client with emphysema has long-standing hypercapnia, the respiratory drive is triggered by a low oxygen level rather than by a high carbon dioxide level. Too much oxygen in this client could cause respiratory failure. The client with emphysema usually receives oxygen at a flow rate of 1 to 2 (and no more than 3) L/min.
A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the primary health care provider before administering the dose? 3.0 mEq/L (3.0 mmol/L) 5.2 mEq/L (5.2 mmol/L) 4.2 mEq/L (4.2 mmol/L) 3.8 mEq/L (3.8 mmol/L)
3.0 Furosemide is used to treat hyperkalemia. Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A result of 3.0 mEq/L (3.0 mmol/L) is low, 3.8 and 4.2 mEq/L (3.8 and 4.2 mmol/L) are normal, and 5.2 mEq/L (5.2 mmol/L) is high. Administering furosemide to a client with a low potassium level and a history of cardiovascular disease could precipitate ventricular dysrhythmias in the client. The normal and high levels do not require withholding of the dose. In fact, the high level may be lowered by administration of the medication, which is a potassium-losing diuretic.
A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? 9% 15% 10% 7%
7% Rationale: An acceptable measure of diabetic control is present if the client's glycosylated HbA1C is 7.0% or less. Specific values may vary slightly, depending on the laboratory and the procedure. The other options indicate poor control of diabetes.
A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teaching if the client indicates planning to do what as part of aftercare? Call the primary health care provider if excessive drainage from the wound occurs Apply cool compresses to the site twice a day for 20 minutes Use the antibiotic ointment as prescribed Return in 7 days to have the sutures removed
Apply cool compress to the site twice a day for 20 minutes Rationale: Cool compresses are not used on biopsy sites. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After dressing removal, the site is kept clean and dry but may be cleansed daily with tap water or saline solution. The primary health care provider may prescribe an antibiotic ointment to minimize local bacterial colonization, and the ointment should be used as directed. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy.
A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. Applying suction throughout the procedure Placing the client in a supine position before the procedure Assessing breath sounds before suctioning Hyperoxygenating the client with 100% oxygen before suctioning Setting the suction pressure to 60 mm Hg
Applying suction throughout the procedure Placing the client in a supine position before the procedure Setting the suction pressure to 60 mmHg Rationale: The client with a tracheostomy tube should be positioned with the head of the bed elevated. Correct suction pressure for the adult client is 80 to 120 mm Hg. Suction is applied intermittently during catheter withdrawal. Breath sounds should be assessed before the procedure to help determine the need for suctioning. The client should be hyperoxygenated with 100% oxygen before suctioning.
A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? Check tubes and drains for patency Assess the patency of the airway Check the dressing for bleeding Assess the vital signs to compare them with preoperative measurements
Assess the patency of the airyway Rationale: The first action of the nurse is to assess the patency of the airway. The nurse then performs an assessment of cardiovascular function, the condition of the surgical site, the patency of tubes and drains for patency, and the function of the central nervous system. If the airway is not patent, immediate measures must be taken to help ensure the survival of the client.
A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? Bleeding Infection at the site Increased temp Renal colic
Bleeding Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs/symptoms of infection would not appear immediately after a biopsy. There is no information in the question to indicate the presence of renal colic.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? Encourage the client to cough out the bloody secretions Check the degree of suction being applied Remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth Continue suctioning to remove the blood
Check the degree of suction being applied Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions.
A client who has just gone undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? a. Attaching the client to a cardiac monitor b. Ensuring that the intravenous (IV) line is patent c. Preparing the client for a perfusion scan d. Administering oxygen by way of nasal cannula
D. PE is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress and central cyanosis, pcp notified.
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect? Decrease the client's oxygen-based respiratory drive Increase the risk of pneumonia as a result of drier air passages Decrease the client's carbon dioxide-based respiratory drive Be drying to nasal passages
Decrease the client's oxygen-based respiratory drive Rationale: Normally the respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural drive becomes ineffective after exposure to a high carbon dioxide level over a prolonged period. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD cannot increase the oxygen level independently because this could halt the respiratory drive, leading to respiratory failure.
A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs/symptoms does the nurse anticipate that this client will exhibit? Increased heart rate and increased blood pressure Decreased heart rate and decreased blood pressure Increased heart rate and decreased blood pressure Decreased heart rate and increased blood pressure
Decreased heart rate and decreased blood pressure Rationale: Hypothermia decreases the heart rate and blood pressure, because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases, with corresponding drops in both heart rate and blood pressure.
A client with a history of lung disease is at risk for respiratory acidosis. For which signs/symptoms does the nurse assess this client? Drowsiness, headache, and tachypnea Disorientation and dyspnea Tachypnea, dizziness, and paresthesias Dysrhythmias and decreased respiratory rate and depth
Disorientation and dyspnea Rationale: The client with respiratory acidosis would exhibit the signs/symptoms identified in the correct option. The client will experience dyspnea and may be disoriented as a result of hypoxia and retention of carbon dioxide. Metabolic acidosis and alkalosis are marked by drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively. The client with respiratory alkalosis is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities.
A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs/symptoms should the nurse assess the client to determine whether the tamponade is recurring? Falling central venous pressure Decreasing pulse Distant muffled heart sounds Rising blood pressure
Distant muffled heart sounds Rationale: After effective pericardiocentesis, an increase in blood pressure and a decrease in CVP are expected. The pulse may slow because less cardiac work is needed to produce adequate cardiac output. Distant muffled heart sounds that were noted before the test should become clear with effective pericardiocentesis. A return of distant muffled heart sounds indicates returning pericardial effusion and possible tamponade.
Polyethylene glycol-electrolyte solution is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? Administering a cleaning enema Documenting the diarrhea in the medical record Giving IV replacement fluids in large amounts Calling the PCP
Documenting the diarrhea in the medical record Rationale: Polyethylene glycol-electrolyte solution, also known as GoLYTELY, is a bowel evacuant used in preparation for colonoscopy to cleanse the bowel. It is expected to cause mild diarrhea and will clear the bowel in 4 to 5 hours. Therefore the appropriate action is for the nurse to document the results in the medical record. The other options are incorrect or unnecessary.
A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving pre-procedure instructions tell the client that is important to do before the procedure? Wear comfortable clothing and shoes Drink 6-8 glasses of water without voiding Stop eating or drinking at midnight before the test Eat only a light breakfast
Drink 6-8 glasses of water without voiding Rationale: Pelvic ultrasound requires the ingestion of a large volume of water just before the procedure. A full bladder helps ensure that the bladder is easily visualized and not mistaken for a pelvic growth. A client undergoing abdominal (not pelvic) ultrasound may have to refrain from eating or drinking for several hours before the procedure.
A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs/symptoms does the nurse assess this client? Disorientation and dyspnea Drowsiness, headache, and tachypnea Dysrhythmias and decreased respiratory rate and depth Tachypnea, dizziness, and paresthesias
Dysrhythmias and decreased respiratory rate and depth Rationale: The client with metabolic alkalosis is likely to exhibit dysrhythmias and a decreased respiratory rate and depth as a compensatory mechanism. The client with metabolic acidosis would exhibit the signs/symptoms such as drowsiness, headache, and tachypnea. The client with respiratory acidosis or alkalosis would exhibit the disorientation and dyspnea or tachypnea, dizziness, and paresthesias, respectively.
The nurse is caring for a client with a diagnosis of suspected uric acid calculi. The nurse is carefully checking the history of the client. What areas should the nurse focus on? Select all that apply. History of anemia Family history of urinary calculi Previous episodes of stone formation Dietary supplements Previous problems with fluid overload 8.9 mg/dL (529.9 μmol/L) Prescribed and OTC medications
Family history of urinary calculi Previous episodes of stone formation Dietary supplements Prescribed and OTC medications Rationale: A careful history should include any previous episodes of uric acid stone formation, prescribed and OTC medications, dietary supplements, and family history of urinary calculi. A history of anemia and fluid overload are not related to uric acid calculi areas.
A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? Side-lying with the head of the bed elevated Semi-Fowler Flat Sitting up in a recliner with the feet elevated
Flat Rationale: After lumbar puncture, the client must remain flat for as long as 12 hours to help prevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the other options are incorrect.
A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath followed by what client action? Breathe normally during tube removal Bear down during tube removal Exhale during tube removal Hold the breath during tube removal
Hold the breath during tube removal Rationale: The client is asked to take a deep breath because the airway will be temporarily obstructed during tube removal. The client is then asked to hold the breath while the tube is being withdrawn. Bearing down and exhaling could each interfere with tube removal by increasing intrathoracic pressure. Normal breathing could result in aspiration of gastric secretions during inhalation.
An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse that some of the client's lab data are abnormal? Select all that apply. LDL Cholesterol 140 Magnesium (MG) 2.2 mEq/L Calcium (CA) 9 mg/dL Sodium (NA) 149 mEq/L Bicarbonate 21 mEqL Hematocrit (HCT) 30% (0.30)
LDL Cholesterol 140 Sodium 149 mEq/L Bicarbonate 21 mEqL HCT 30% Rationale: A sodium (NA) level of 149 is elevated. Normal NA levels are 135 to 145 mEq/L. Hematocrit (HCT) level of 30% is low. Normal HCT levels are 40% to 54% in males and 37% to 47% in females. Calcium (CA) 9 mg/dL is normal. Normal calcium levels are8.5 to 10.5 mg/dL. LDL Cholesterol 140 is borderline high. Optimal LDL is 100 to 129. Magnesium 2.2 mEq/L is normal. Normal magnesium levels are 1.5 to 2.5 mEq/L. Bicarbonate level of 21 mEqL is low. Normal bicarb is 24 to 28 mEq/L.
A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? Loss of cough reflex Hypertension Low blood pressure Infection
Low blood pressure Rationale: Hypotension, shock, and the use of peripheral vasoconstricting medications may each result in inaccurate pulse oximetry readings because of the impairment of peripheral perfusion. The other options listed would not produce inaccurate readings.
A nurse is getting a client out of bed for the first since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? Check the client's bp Have the client take some deep breaths Check ox sat level Lower the head of the bed slowly until the dizziness is relieved
Lower the head of the bed slowly until the dizziness is relieved Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse should first lower the head of the bed slowly until the dizziness is relieved. The nurse then checks the client's pulse and blood pressure. Because the problem is circulatory, not respiratory, checking the oxygen saturation level and having the client take some deep breaths are not the first actions to be taken.
A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis
Metabolic alkalosis Rationale: Oral antacids commonly contain sodium or calcium bicarbonate or other alkaline components. These substances bind to the hydrochloric acid in the stomach to neutralize it. Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis over time.
A nurse is reading the radiology report of a client who has a chest tube attached to a closed drainage system and has undergone chest x-ray. The report states that the client's affected lung is fully re-expanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? Continuous bubbling in the water seal chamber Increased drainage in the collection chamber No fluctuation in the water seal chamber Continuous gentle suction in the suction control chamber
No fluctuation in the water seal chamber Rationale: When the client's lung is fully re-expanded, the drainage system will no longer drain and fluctuation in the water seal chamber will be absent. This is because the lung has re-expanded and the pleural space is again a potential space. Continuous bubbling in the water seal chamber indicates an air leak in the system. Continuous gentle suction in the suction control chamber means that suction is being applied to the system.
A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason? Feeling dual pulsations may lead to an incorrect measurement Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop Palpating both carotid pulses simultaneously could occlude the trachea It is unnecessary to use both hands
Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop Rationale: Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. In addition, the manual pressure could interfere with the flow of blood to the brain, possibly causing dizziness and syncope.
A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? Pulmonary artery end-diastolic pressure Pulmonary artery systolic pressure Blood pressure Pulse rate
Pulse rate Rationale: Cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Remember that pulse rate multiplied by stroke volume equals cardiac output. An increase in pulse is often sufficient with small amounts of volume depletion to maintain the blood pressure. Pulmonary artery systolic pressure and pulmonary artery end-diastolic pressure, measurements obtained with the use of a pulmonary artery catheter, provide information about the pressures in the pulmonary artery and in the left ventricle at the end of diastole.
A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? Encouraging fluid intake Questioning the client about allergies to iodine or shellfish Administering a sedative Administering an oral preparation of radiopaque dye
Questioning the client about allergies to iodine or shellfish Rationale: Some IVP dyes are iodine based; if the dye to be used in this procedure is one of them and the client has an allergy to iodine or shellfish, he may experience an allergic reaction, manifested as itching, hives, rash, a tight feeling in the throat, shortness of breath, or bronchospasm. For this reason, assessing the client for allergies is the priority. The dye is injected intravenously. The client may or may not receive premedication. Nothing-by-mouth status is generally imposed after midnight on the day before the test.
A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing pre-procedure instructions, should tell the client to implement which measure? Remove all metal and jewelry before the test Take all oral medications as scheduled with milk on the day of the test Expect diarrhea for a few days after the procedure Eat a regular supper and a breakfast
Remove all metal and jewelry before the test Rationale: A barium swallow, or esophagography, is an x-ray in which a substance called barium is used to provide contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test so it won't interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on the primary health care provider's instructions. Most oral medications are withheld before the test. The client should self-monitor for constipation, which may occur as a result of the presence of barium in the GI tract, after the procedure.
A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The primary health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink? Ox sat monitor Napkin Suction Equipment Straw
Suction equipment Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The nurse checks the gag and swallow reflexes before offering fluids to the client, but suction equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the formation of flatus, resulting in gastrointestinal discomfort.
A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs/symptoms of respiratory alkalosis does the nurse assess this client? Tachypnea, dizziness, and paresthesias Drowsiness, headache, and tachypnea Dysrhythmias and decreased respiratory rate and depth Disorientation and dyspnea
Tachypnea, dizziness, and paresthesias Rationale: The client who is anxious is at risk for respiratory alkalosis as a result of hyperventilation. The client is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities. The client with respiratory acidosis would exhibit disorientation and dyspnea. The client with metabolic acidosis or alkalosis would exhibit signs/symptoms such as drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively.
A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? Monitoring the client for a sore throat Giving the client a drink of water Taking the client's vital signs Being alert to complaints of heartburn
Taking the client's vital signs Rationale: The nurse would first assess the client for the return of the gag reflex, which is part of managing the client's airway. The client's vital signs should be checked next; a sudden sharp increase in temperature could indicate perforation of the gastrointestinal tract (this would be accompanied by other signs/symptoms, such as pain, as well). Monitoring the client for sore throat and heartburn is also important but is of lesser priority than ensuring a patent airway. Water or any other fluid would not be given to the client until the gag reflex had returned and the client was stable.
A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? Assessing the client's chest for crepitus once every 24 hours Adding 20 mL of sterile water to the suction control chamber every shift Taping the connections between the chest tube and the drainage system Recording the volume of secretions in the drainage collection chamber every 24 hours
Taping the connections between the chest tube and the drainage system Rationale: The nurse tapes all system connections to prevent accidental disconnection. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. Assessment for crepitus is performed once every 8 hours or more often if needed. Sterile water is only added to the suction control chamber as needed to replace evaporative loss.
A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? That there is no discomfort associated with the procedure Not to eat or drink on the morning of the test That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test That mammography takes about 1 hour
That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test Rationale: The client should avoid using deodorants, powders, or creams on the day of the mammogram; such products used in the axillary or breast must be washed off before the test. The client may experience some discomfort because it is necessary to compress the breast tissue to obtain a clear image. The client may eat and drink before the procedure, which generally takes 15 to 30 minutes to complete.
A nurse is reading the chest x-ray report of a client who has just been intubated. The report states where the endotracheal tube is positioned. What finding is considered a normal position for the endotracheal tube? The bifurcation of the right and left main stem bronchi The first tracheal cartilaginous ring The area connecting the oropharynx to the laryngopharynx The point where the larynx connects to the trachea
The bifurcation of the right and left main stem bronchi Rationale: The normal position of the tube is above the bifurcation of the right and left main stem bronchi.
A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? The amount of drainage The chest tube connections The client's vital signs The client's lung sounds
The chest tube connections Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires primary health care provider intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's signs/symptoms should resolve.
A nurse reviews a client's urinalysis report. Which findings does the nurse recognize as abnormal? Select all that apply. pH of 6.0 The presence of ketones An absence of protein Glucose noted Specific gravity of 1.018 Casts apparent
The presence of ketones Glucose noted Casts apparent Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from 1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, none of which should be present.
A client has made an appointment for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should provide which information to the client? Vaginal douching is required an hour before the test Spicy foods should not be eaten on the day of the test The test cannot be performed while the client is menstruating The test has absolutely no discomfort associated with it
The test cannot be performed while the client is menstruating Rationale: A Pap smear cannot be performed with accurate results during menstruation. The test is usually painless but may be slightly uncomfortable during placement of the speculum or while the cervical scraping is obtained. The client should not douche for at least 24 hours before the test. There is no reason to restrict consumption of spicy foods on the day of the test.
A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? The client probably has an opportunistic infection The test will need to be confirmed with the use of a Western blot HIV infection has been confirmed A positive test is a normal result and does not mean that the client is infected with HIV
The test will need to be confirmed with the use of a Western blot Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be confirmed with the use of the Western Blot. The other options are incorrect.
A nurse in a primary health care provider's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? Avoid consuming caffeine for 30 minutes before the procedure Wear sweatpants and a heavy sweatshirt Eat a small meal just before the procedure Wear comfortable rubber-soled shoes such as sneakers
Wear comfortable rubber-soled shoes such as sneakers Rationale: The client should wear comfortable rubber-soled shoes, such as sneakers, for the procedure. The client wears light, loose, comfortable clothing; a shirt that buttons in front is helpful for electrocardiogram (ECG) lead placement. The client should be NPO after bedtime, or for a minimum of 2 hours before the test, and should avoid tobacco, alcohol, and caffeine on the day of the test.
