Question

A nurse is planning care for a client who has a chest tube. Which of the...

  1. A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the care of plan? (select all that apply)
    • a. Maintain the collection chamber above the level of the client’s waist
    • b. Clamp the chest tube every 2 hr to assess the amount of drainage
    • c. Strip the chest tube vigorously to dislodge blood clots
    • d. Mark the drainage output on the collection chamber hourly
    • e. Add water to the water seal chamber as it evaporates
  2. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps the nurse manager should plan to take in response to the staff member’s conduct.
    • a. Verbally remind the staff member of the expected behavior changes
    • b. Set up a meeting to speak with the staff member about the behavior
    • c. Give the staff member a written warning about the behavior
    • d. Suspend the staff member from work for several days
    • e. Dismiss the staff member from employment at the facility
  3. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hrs earlier. Which of the following statements should the nurse make? (pg- 77)
    • a. I can start the medication 30 minutes earlier
    • b. I can adjust the time and schedule for when it’s convenient for you
    • c. I can infuse the medication at a faster rate
    • d. I have up to 2 hours after the usual schedule time to give you this mediation
  4. A nurse is teaching a childbirth education class and is discussing sexual intercourse during pregnancy. Which of the following statements should the nurse make?
    • a. The female superior position can be used during the third trimester of pregnancy
    • b. Your sexual desire might increase during the first trimester of pregnancy
    • c. You should limit the frequency of intercourse after 34 weeks of pregnancy
    • d. Frequent intercourse increases the risk for miscarriage in early pregnancy
  5. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical mastectomy. Which of the following statements by the client indicates an understanding of the teaching?
    • a. I can shower within 48 hours of my surgery
    • b. I will complete my arm exercise four times a day
    • c. I will have my drains removed 1 hour prior to going home
    • d. I can begin to drive 24 hours after surgery
  6. A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?
    • a. Rectal
    • b. Axillary
    • c. Tympanic
    • d. Oral
  7. A nurse is caring for a client who is 12 hr postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
    • a. Report of pain level of 5 on a scale of 0 to 10
    • b. Burgundy-colored urine
    • c. Urgency to void
    • d. Passage of small clots
  8. A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
    • a. Implement firm but flexible boundaries in their relationship
    • b. Decrease socialization with extended relative until roles are identified
    • c. Minimize open discussion regarding the changes to avoid embarrassment
    • d. Encourage authoritative communication form the adult child
  9. A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
    • a. Oliguria
    • b. Bulging anterior fontanel
    • c. Hypertension
    • d. Decreased temperature
  10. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 1 min with a 45- second duration, and the fetal heart rate is 170-180/min. Which of the following actions should the nurse take?
    • a. Discontinue the oxytocin infusion
    • b. Relieve pressure on the umbilical cord
    • c. Administer calcium gluconate
    • d. Apply and internal fetal heart rate monitor
  11. A nurse is assessing a client who has heart failure and is prescribed a 2,000 mL 24 hr fluid restriction. Which of the following findings should the nurse report to the provider?
    • a. Urinary output of 420 mL in 8 hr
    • b. Oral intake of 300mL in 8 hr
    • c. Watery stools of 400mL in 8 hr
    • d. Intravenous intake of 240 mL in 8 hr
  12. A nurse is caring for a client who is in labor and receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
    • a. Montevideo units consistently 300 mm Hg
    • b. Urine output of 20mL/hr
    • c. Contractions every 5 min that last 30 seconds
    • d. FHR pattern with absent variability

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Homework Answers

Answer #1
  • Mark the drainage output on the collection chamber hourly
  • Add water to the water seal chamber as it evaporates
  • Strip the chest tube vigorously to dislodge blood clots

Set up a meeting to speak with the staff member about the behavior

Verbally remind the staff member of the expected behavior changes

Give the staff member a written warning about the behavior

I have up to 2 hours after the usual schedule time to give you this mediation

You should limit the frequency of intercourse after 34 weeks of pregnancy

  • b. I will complete my arm exercise four times a day
  • a. Rectal
  • d. Passage of small clots

. Implement firm but flexible boundaries in their relationship

Oliguria

. Apply and internal fetal heart rate monitor

  • a. Urinary output of 420 mL in 8 hr

FHR pattern with absent variability.

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