Question

A nurse is assessing a client who had a pleural chest tube with a water seal chamber inserted 48 hr ago. Which of the following findings should the nurse report to the provider?

Answer 1

Correct Answers:

Drainage in the collection chamber of 640 mL/4 hr

Rationale :

🫁 Drainage of 640 mL in 4 hours should be reported to the provider because it indicates excessive chest tube output that may suggest ongoing bleeding or a complication after chest tube placement.

🫁 A chest tube is used to remove air, blood, or fluid from the pleural space and restore normal lung expansion.

🫁 After insertion, some drainage is expected; however, a large amount of sudden drainage requires further evaluation because it may indicate hemothorax, vascular injury, or continued bleeding.

🫁 The nurse should monitor the amount, color, and characteristics of chest tube drainage and report significant increases promptly.

🫁 Excessive blood loss through the chest tube can lead to hypovolemia, decreased cardiac output, and hemodynamic instability.

🫁 The provider may need to evaluate the client for complications and determine whether additional treatment is required.

🫁 Prompt reporting helps prevent worsening respiratory and circulatory complications.

🫁 This answer is correct because 640 mL of drainage over 4 hours is an abnormal amount requiring provider notification.

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Answer 2

Correct Answers:

"Refrain from wearing any type of artificial nails."

Rationale :

🩺 Refraining from wearing artificial nails is the correct teaching because artificial nails can harbor bacteria and fungi, increasing the risk of central line-associated bloodstream infections (CLABSI).

🩺 Clients with long-term central venous access devices, such as PICC lines, tunneled catheters, or implanted ports, must follow strict infection prevention practices.

🩺 Artificial nails and nail enhancements can make effective hand hygiene more difficult and may contain microorganisms that can contaminate the catheter site or equipment.

🩺 Maintaining clean hands is one of the most important measures to prevent infection in clients with central venous access devices.

🩺 The nurse should teach the client to perform careful hand hygiene before handling the catheter, dressing, or infusion equipment.

🩺 The client should also monitor for signs of infection such as redness, warmth, swelling, drainage, fever, or chills and report these findings promptly.

🩺 Preventing infection is a priority because bloodstream infections related to central lines can become life-threatening.

🩺 This answer is correct because avoiding artificial nails reduces contamination risk and promotes safe central line care.

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Answer 3

Correct Answers:

A client who is receiving chemotherapy and has an absolute neutrophil count below the expected reference range

Rationale :

🛡️ A client receiving chemotherapy with a low absolute neutrophil count (ANC) requires a single-occupancy room with positive pressure ventilation because the client is at high risk for infection due to neutropenia.

🛡️ Positive pressure rooms protect immunocompromised clients by pushing filtered air outward, preventing contaminated air from entering the room.

🛡️ Chemotherapy can suppress bone marrow function, causing neutropenia, which reduces the body’s ability to fight bacterial and fungal infections.

🛡️ A decreased ANC indicates impaired immune defense, making even normally harmless microorganisms potentially dangerous.

🛡️ Protective isolation measures include strict hand hygiene, limiting exposure to infectious individuals, and maintaining a clean environment.

🛡️ The nurse should monitor for signs of infection such as fever, chills, sore throat, and changes in vital signs because neutropenic clients may not develop typical inflammatory responses.

🛡️ Preventing exposure to pathogens is a priority because infections in severely neutropenic clients can progress rapidly.

🛡️ This answer is correct because positive pressure ventilation is used to protect clients with severe immunosuppression, especially those with neutropenia from chemotherapy.

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Answer 4

Correct Answers:

Measure residual volume prior to bolus feedings

Rationale :

🥣 Measuring gastric residual volume before bolus feedings helps the nurse assess whether the stomach is emptying properly and reduces the risk of aspiration.

🥣 A large gastric residual indicates that the client may not be tolerating the enteral feeding, increasing the risk of regurgitation and aspiration into the lungs.

🥣 Before administering a bolus feeding, the nurse should assess gastric contents according to facility policy and provider recommendations.

🥣 The nurse should also maintain the client in a semi-Fowler’s or high-Fowler’s position (30–45 degrees or higher) during feeding and for a period afterward.

🥣 Proper positioning uses gravity to prevent reflux of feeding contents into the airway.

🥣 The nurse should monitor for signs of aspiration such as coughing, choking, decreased oxygen saturation, respiratory distress, and abnormal lung sounds.

🥣 Safe enteral feeding practices improve nutritional support while reducing complications such as aspiration pneumonia.

🥣 This answer is correct because checking residual volume helps identify poor gastric emptying and decreases the chance of aspiration during enteral nutrition.

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Answer 5

Correct Answers:

Decreased blood pressure

Rationale :

🦋 Decreased blood pressure can indicate that the client is receiving an inadequate dosage of levothyroxine because the client may continue to experience effects of hypothyroidism.

🦋 Levothyroxine is a thyroid hormone replacement medication used to increase levels of thyroxine (T4) and restore normal metabolic function.

🦋 When the dose is too low, the body remains in a state of decreased metabolism, causing slowed cardiovascular activity and reduced cardiac output.

🦋 Hypothyroidism can cause bradycardia, fatigue, weight gain, cold intolerance, constipation, and decreased blood pressure due to reduced thyroid hormone activity.

🦋 The nurse should monitor TSH levels and assess whether hypothyroid symptoms are improving to determine if the medication dosage is effective.

🦋 The goal of levothyroxine therapy is to maintain normal thyroid hormone levels and eliminate symptoms caused by insufficient thyroid function.

🦋 Persistent symptoms of hypothyroidism indicate that the client may need a dosage adjustment by the healthcare provider.

🦋 This answer is correct because low blood pressure reflects continued slowed body function from insufficient thyroid hormone replacement.

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Answer 6

Correct Answers:

Monitor the catheterization site for hematoma formation

Rationale :

🫀 Monitoring the catheterization site for hematoma formation is the priority intervention after a cardiac catheterization because the client is at risk for bleeding and vascular complications at the insertion site.

🫀 A vascular closure device is used to help seal the arterial puncture site after catheter removal, but it does not eliminate the risk of bleeding, hematoma, or vessel complications.

🫀 The nurse should frequently assess the access site for swelling, bruising, bleeding, firmness, and increasing size of a hematoma.

🫀 Early detection of a hematoma is important because continued bleeding can lead to decreased circulating volume, hemodynamic instability, and compromised circulation.

🫀 The nurse should also monitor vital signs and compare the affected extremity with the unaffected side for changes.

🫀 Although other assessments are important after cardiac catheterization, identifying and preventing life-threatening bleeding complications is the immediate priority.

🫀 The nurse should maintain appropriate pressure or follow facility protocols if bleeding occurs and notify the provider as needed.

🫀 This answer is correct because post-catheterization bleeding at the vascular access site is the most immediate complication requiring assessment.

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Answer 7

Correct Answers:

Drink 2 to 3 L of fluids daily

Rationale :

🚰 Drinking 2 to 3 liters of fluids daily is the correct teaching because increased fluid intake helps flush bacteria from the urinary tract and decreases the risk of recurrent urinary tract infections (UTIs).

🚰 Ciprofloxacin is a fluoroquinolone antibiotic used to treat bacterial infections, including complicated or recurrent UTIs.

🚰 Adequate hydration helps increase urine production, which promotes removal of bacteria and reduces urinary stasis.

🚰 The nurse should encourage the client to maintain hydration unless contraindicated by another condition such as heart failure or renal impairment.

🚰 Clients taking ciprofloxacin should also be taught to complete the entire prescription, even if symptoms improve, to prevent recurrence and antibiotic resistance.

🚰 Ciprofloxacin absorption can be reduced by calcium, magnesium, aluminum, iron, and zinc-containing products, so patients should separate these products from the medication.

🚰 The nurse should teach the client to report adverse effects such as tendon pain or swelling, severe diarrhea, or allergic reactions.

🚰 This answer is correct because adequate fluid intake supports urinary tract health and helps prevent recurrent UTIs while taking ciprofloxacin.

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Answer 8

Correct Answers:

Placing their affected leg on a step first when going up stairs

Rationale :

🦯 Placing the affected leg on a step first when going up stairs places the client at risk for injury because the unaffected (stronger) leg should go up first when climbing stairs with crutches.

🦯 The correct stair sequence is “up with the good, down with the bad”.

🦯 When going up stairs, the client should advance the unaffected leg first, followed by the crutches and the affected leg.

🦯 When going down stairs, the client should move the crutches and affected leg first, then bring down the unaffected leg.

🦯 Leading with the affected leg while climbing requires the weaker extremity to support more weight, increasing the risk of loss of balance and falling.

🦯 The nurse should reinforce proper crutch technique to promote safety and prevent injury during ambulation.

🦯 Correct use of assistive devices helps the client maintain mobility while protecting the injured or weakened extremity.

🦯 This answer is correct because placing the weak leg first while going upstairs increases fall risk.

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Answer 9

Correct Answers:

Agitation

Rationale :

🫁 Agitation is an early indication of respiratory failure because inadequate oxygen delivery to the brain can cause restlessness, anxiety, confusion, and changes in mental status.

🫁 Respiratory failure occurs when the lungs cannot maintain adequate oxygenation (PaO₂) or remove enough carbon dioxide (PaCO₂) from the blood.

🫁 The brain is highly sensitive to oxygen deprivation, so altered mental status is often one of the earliest signs of worsening respiratory function.

🫁 A client with respiratory failure may progress from agitation and restlessness to confusion, lethargy, and decreased level of consciousness as hypoxia worsens.

🫁 The nurse should assess additional respiratory indicators such as oxygen saturation, respiratory rate, work of breathing, breath sounds, and arterial blood gases (ABGs).

🫁 Early recognition of agitation allows prompt intervention, such as improving oxygen delivery and addressing the underlying cause of respiratory compromise.

🫁 Delayed treatment can result in severe hypoxemia, organ dysfunction, and respiratory arrest.

🫁 This answer is correct because agitation is a classic early neurological sign of inadequate oxygenation in respiratory failure.

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Answer 10

Correct Answers:

Place the drainage system lower than the client's chest

Rationale :

🫁 Placing the drainage system lower than the client’s chest is the correct intervention because it allows gravity drainage of air and fluid from the pleural space into the collection chamber.

🫁 A chest tube drainage system with a dry suction water seal works by creating a one-way valve system that allows air and fluid to leave the chest while preventing backflow into the pleural cavity.

🫁 Keeping the drainage device below the level of the chest prevents fluid from flowing backward into the pleural space, which could worsen respiratory compromise.

🫁 The nurse should ensure the system remains upright and below chest level during movement, transfers, and ambulation.

🫁 The nurse should also assess for proper functioning by monitoring tidaling in the water seal chamber and checking for expected suction indicators according to the device type.

🫁 Proper placement helps maintain lung re-expansion and prevents complications such as recurrent pneumothorax or impaired drainage.

🫁 Safe management of chest tube systems is essential because malfunction can quickly affect the client’s breathing and oxygenation.

🫁 This answer is correct because keeping the drainage system below the chest promotes effective drainage and prevents backflow.

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QLexNursing

1 :
A nurse is assessing a client who had a pleural chest tube with a water seal chamber inserted 48 hr ago. Which of the following findings should the nurse report to the provider?

2 :
A nurse is preparing to discharge a client who has a long-term central venous access device. Which of the following statements should the nurse make?

3 :
A nurse is preparing to admit a group of clients. Which of the following clients should the nurse place in a single-occupancy room with positive pressure ventilation?

4 :
A nurse is caring for a client who is receiving enteral nutrition. Which of the following actions should the nurse take to reduce the client's risk of aspiration?

5 :
A nurse is caring for a client who has hypothyroidism and is receiving levothyroxine. Which of the following findings should the nurse identify as an indication the client is receiving an inadequate dosage of the medication?

6 :
A nurse is planning care for a client immediately following a cardiac catheterization who has a vascular closure device in place. Which of the following interventions is the nurse's priority when providing care to the client?

7 :
A nurse is providing discharge teaching to a client who has chronic UTIs. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

8 :
A nurse is observing the gait of a client who uses crutches and has been taught to use a three-point gait. Which of the following actions places the client at risk for injury?

9 :
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?

10 :
A nurse is caring for a client who has a chest tube drainage system with a dry suction water seal. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is assessing a client who had a pleural chest tube with a water seal chamber inserted 48 hr ago. Which of the following findings should the nurse report to the provider?

2 : A nurse is preparing to discharge a client who has a long-term central venous access device. Which of the following statements should the nurse make?

3 : A nurse is preparing to admit a group of clients. Which of the following clients should the nurse place in a single-occupancy room with positive pressure ventilation?

4 : A nurse is caring for a client who is receiving enteral nutrition. Which of the following actions should the nurse take to reduce the client's risk of aspiration?

5 : A nurse is caring for a client who has hypothyroidism and is receiving levothyroxine. Which of the following findings should the nurse identify as an indication the client is receiving an inadequate dosage of the medication?

6 : A nurse is planning care for a client immediately following a cardiac catheterization who has a vascular closure device in place. Which of the following interventions is the nurse's priority when providing care to the client?

7 : A nurse is providing discharge teaching to a client who has chronic UTIs. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

8 : A nurse is observing the gait of a client who uses crutches and has been taught to use a three-point gait. Which of the following actions places the client at risk for injury?

9 : A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?

10 : A nurse is caring for a client who has a chest tube drainage system with a dry suction water seal. Which of the following actions should the nurse take?

1 :
A nurse is assessing a client who had a pleural chest tube with a water seal chamber inserted 48 hr ago. Which of the following findings should the nurse report to the provider?

2 :
A nurse is preparing to discharge a client who has a long-term central venous access device. Which of the following statements should the nurse make?

3 :
A nurse is preparing to admit a group of clients. Which of the following clients should the nurse place in a single-occupancy room with positive pressure ventilation?

4 :
A nurse is caring for a client who is receiving enteral nutrition. Which of the following actions should the nurse take to reduce the client's risk of aspiration?

5 :
A nurse is caring for a client who has hypothyroidism and is receiving levothyroxine. Which of the following findings should the nurse identify as an indication the client is receiving an inadequate dosage of the medication?

6 :
A nurse is planning care for a client immediately following a cardiac catheterization who has a vascular closure device in place. Which of the following interventions is the nurse's priority when providing care to the client?

7 :
A nurse is providing discharge teaching to a client who has chronic UTIs. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

8 :
A nurse is observing the gait of a client who uses crutches and has been taught to use a three-point gait. Which of the following actions places the client at risk for injury?

9 :
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?

10 :
A nurse is caring for a client who has a chest tube drainage system with a dry suction water seal. Which of the following actions should the nurse take?