Question

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

Answer 1

Correct Answers:

1 cm of water present in the water seal chamber

Rationale :

🔵 The water seal chamber of a chest drainage system must contain exactly 2 cm of sterile water to create a proper one-way valve that prevents air from re-entering the pleural space.

🔵 Only 1 cm of water indicates inadequate sealing, which could allow air to flow back into the chest cavity, leading to pneumothorax recurrence or compromised lung expansion.

🔵 Nurses must routinely assess and maintain the correct water level in the chamber; if it's low, sterile water should be added immediately under sterile technique.

🔵 All other findings are expected and normal:

— Tidaling reflects pressure changes with breathing.

— -20 cm H₂O suction is standard for adult chest drainage.

— A partially full drainage collection chamber is normal unless there’s sudden increase in volume or presence of bright red blood.

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Answer 2

Correct Answers:

Use a designated stethoscope when caring for the toddler.

Rationale :

🟢 Respiratory Syncytial Virus (RSV) is transmitted via direct contact with contaminated surfaces or respiratory secretions, not through airborne particles.

🟢 The nurse should implement contact precautions, which include wearing gown and gloves and using dedicated patient care equipment like a stethoscope and thermometer.

🟢 This prevents cross-contamination and the spread of RSV to other vulnerable pediatric patients.

🟢 The nurse should also follow standard droplet precautions (mask if within 3 feet), but N95 masks and negative pressure rooms are not required unless there's aerosol-generating procedures involved.

🟢 Gowns must be removed before exiting the room to prevent spreading pathogens outside the isolation area.

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Answer 3

Correct Answers:

Clients who have a history of viral hepatitis are unable to donate blood.

Rationale :

📌Individuals with a history of viral hepatitis, particularly hepatitis B or C, are permanently deferred from donating blood due to the risk of transmitting the virus to recipients through transfusion.

📌Hepatitis viruses can remain in the body and pose latent risks even if the person is asymptomatic, making blood donation unsafe.

📌Blood donation centers have strict screening criteria to ensure blood supply safety, and a past history of viral hepatitis disqualifies a potential donor.

📌This recommendation is part of universal blood safety protocols enforced globally to prevent transfusion-transmitted infections.

📌The nurse should clarify common misconceptions about transmission and prevention, and emphasize lifetime blood donor restrictions for certain viral infections.

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Answer 4

Correct Answers:

The client takes aspirin daily.

Rationale :

🟢 Garlic supplements have natural antiplatelet properties, which can increase the risk of bleeding when taken concurrently with other anticoagulant or antiplatelet agents like aspirin.

🟢 Aspirin irreversibly inhibits platelet aggregation, and when combined with garlic, the additive effect can lead to excessive bleeding, especially before surgery or in cases of trauma.

🟢 Clients taking both garlic and aspirin should be monitored closely or advised to discontinue garlic before surgical or dental procedures.

🟢 There is no strong contraindication between garlic and antidepressants, seizure disorders, or rheumatoid arthritis unless interacting medications are involved.

🟢 Nurses should always assess herbal supplement use to ensure safe medication practices and prevent complications.

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Answer 5

Correct Answers:

Provide high-calorie nutritional supplements.

Rationale :

🟡 Clients in acute mania exhibit increased physical activity, excessive talking, and poor concentration, often neglecting food and fluid intake due to distractibility.

🟡 Providing high-calorie, easily consumable nutritional supplements supports metabolic needs when the client cannot sit for full meals.

🟡 Supplements are also useful because they can be consumed quickly while the client continues to pace or talk, maintaining safety and nutrition simultaneously.

🟡 This intervention helps prevent weight loss, dehydration, and nutritional deficiencies common during manic episodes.

🟡 It also reduces the stimulation of long mealtimes, which can be overwhelming and disruptive for manic individuals.

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Answer 6

Correct Answers:

Chlorine bleach

Rationale :

🔷 Chlorine bleach (sodium hypochlorite) is the recommended disinfectant for cleaning surfaces contaminated with blood or body fluids due to its broad-spectrum antimicrobial activity.

🔷 The CDC recommends a 1:10 dilution of bleach for disinfecting blood spills to effectively kill HIV, HBV, HCV, and other bloodborne pathogens.

🔷 Bleach works by denaturing proteins and disrupting cell membranes, ensuring effective decontamination.

🔷 It is fast-acting, inexpensive, and widely available, making it the preferred choice in healthcare settings.

🔷 Other agents like hydrogen peroxide and alcohol are less effective against bloodborne viruses and do not meet OSHA or CDC standards for blood spill cleanup.

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Answer 7

Correct Answers:

Hepatosplenomegaly

Rationale :

🔶 Right ventricular heart failure results in blood backing up into the systemic venous circulation, leading to venous congestion in organs like the liver and spleen.

🔶 This congestion causes hepatosplenomegaly—an enlargement of both the liver and spleen—which is a classic physical finding.

🔶 Clients may also exhibit jugular venous distention, peripheral edema, and ascites, all signs of fluid overload due to impaired right heart function.

🔶 Hepatosplenomegaly can also cause abdominal discomfort and anorexia, which are common complaints in these patients.

🔶 Recognition of these findings helps in differentiating right-sided from left-sided heart failure, which more commonly causes pulmonary symptoms.

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Answer 8

Correct Answers:

The nurse should pad the bony prominences.
The nurse should remove the restraints every 2 hr.
The provider's prescription should include the type of restraint to use.

Rationale :

The nurse should pad the bony prominences.

🔷 Padding bony prominences such as wrists or ankles before applying restraints helps prevent skin breakdown, pressure injuries, and nerve damage.

🔷 Clients in restraints are at high risk for impaired circulation and skin integrity issues, so protective measures are critical.

🔷 Padding also promotes comfort and reduces the risk of injury from friction or pressure caused by the restraint.

The nurse should remove the restraints every 2 hr.

🔷 Restraints should be removed at least every 2 hours to allow for range of motion, toileting, nutrition, and skin assessment.

🔷 This action ensures the client’s safety and dignity while reducing the complications associated with immobility.

🔷 During these intervals, nurses should also reassess the need for continued restraint and document findings accordingly.

The provider's prescription should include the type of restraint to use.

🔷 A restraint order must be complete and specific, stating the type of restraint, the reason, and the duration.

🔷 Federal regulations and facility protocols require that the use of restraints be clinically justified and time-limited.

🔷 This ensures legal compliance and promotes appropriate and individualized use of restraints.

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Answer 9

Correct Answers:

Use a dedicated stethoscope.

Rationale :

🔴 Neutropenic clients are immunocompromised and highly susceptible to opportunistic infections, including those transmitted via contaminated equipment.

🔴 Using a dedicated stethoscope for this client reduces the risk of cross-contamination from other clients or environments.

🔴 This aligns with protective (reverse) precautions, which focus on protecting the client from external pathogens.

🔴 Additional neutropenic precautions include strict hand hygiene, avoiding invasive procedures unless necessary, and minimizing exposure to infectious agents.

🔴 These clients often have decreased white blood cell counts, and even minor infections can progress rapidly, making infection prevention essential.

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Answer 10

Correct Answers:

Hepatitis A

Rationale :

🟡 Hepatitis A is a reportable disease to the Centers for Disease Control and Prevention (CDC) due to its potential to cause community outbreaks and its fecal-oral transmission route.

🟡 Reporting allows for timely public health interventions, including contact tracing, vaccination, and education to prevent further spread.

🟡 The CDC maintains a National Notifiable Diseases Surveillance System (NNDSS), which includes Hepatitis A as a nationally notifiable condition.

🟡 Other reportable types include Hepatitis B and C, but not typically HSV-1 or HPV unless part of surveillance studies.

🟡 Nurses play a vital role in identifying and reporting communicable diseases to protect public health and guide policy.

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QLexNursing

1 :
A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

2 :
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

3 :
A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?

4 :
A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

5 :
A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

6 :
A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?

7 :
A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

8 :
A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

9 :
A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

10 :
A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC?

QLexNursing

1 : A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

2 : A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

3 : A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?

4 : A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

5 : A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

6 : A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?

7 : A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

8 : A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

9 : A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

10 : A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC?

1 :
A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

2 :
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

3 :
A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?

4 :
A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

5 :
A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

6 :
A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?

7 :
A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

8 :
A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

9 :
A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

10 :
A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC?