Question

Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?

Answer 1

Correct Answers:

Continue to monitor the drainage system.

Rationale :

🌬️The rise and fall of the water level in the water-seal chamber with respiration indicates normal fluctuation, or “tidaling,” and shows that the chest tube is patent.

💁‍♂️This movement demonstrates that intrapleural pressure changes are transmitted through the tubing, meaning the tube is functioning.

🩺Auscultation or inspecting for leakage may be indicated if abnormal signs appear, but tidaling is expected at this stage.

⚠️There is no current indication of blockage, air leak, or dislodgment based on the observation provided.

📋In this scenario, the appropriate action is to continue regular monitoring without intervention.

📌Core Message

Water-seal tidaling indicates a patent chest tube, so the nurse should continue monitoring without intervention.

Answer 2

Correct Answers:

An acutely distended bladder.

Rationale :

🚨Autonomic dysreflexia is a medical emergency typically triggered by noxious stimuli below the level of spinal injury, most commonly a distended bladder.

🧠It results in sudden hypertension, bradycardia, headache, and diaphoresis, and the nurse must identify and eliminate the cause quickly.

💉While the symptoms like headache and sweating are important findings, they are effects, not causes.

🛏️Skeletal traction misalignment is not the most likely cause of this autonomic reaction.

📋The nurse must assess for bladder distention first, then remove the trigger to stop the dysreflexia.

📌Core Message

Bladder distention is the most common cause of autonomic dysreflexia and must be addressed immediately.

Answer 3

Correct Answers:

10

Rationale :

🧮The concentration of insulin is 100 units in 100 mL, which equals 1 unit per 1 mL.

💉If the prescribed dose is 10 units/hour, then the nurse should program the pump to deliver 10 mL/hour.

📊No conversion is necessary since the unit-to-mL ratio is 1:1.

📋This ensures the patient receives the correct insulin dosage per hour as ordered.

⚖️Accurate pump programming is vital in IV insulin infusions to avoid hypo- or hyperglycemia.

📌Core Message

With a 1:1 concentration, 10 units/hour equals 10 mL/hour.

Answer 4

Correct Answers:

Sputum culture positive for Mycobacterium tuberculosis.

Rationale :

🧫A definitive diagnosis of active TB is made through a positive sputum culture that identifies the presence of Mycobacterium tuberculosis.

📋PPD and chest x-ray are screening tools, not confirmatory tests.

🔬The culture confirms active infection and guides treatment decisions.

💬Hemoccult testing may indicate bleeding but not TB diagnosis.

🧠This step is crucial for infection control and public health management.

📌Core Message

A sputum culture confirming M. tuberculosis provides a definitive diagnosis of TB.

Answer 5

Correct Answers:

Continue the prescribed dose of lactulose.

Rationale :

💩Lactulose helps decrease serum ammonia by promoting excretion through the bowels, which is critical in hepatic encephalopathy.

📈An elevated ammonia level indicates the drug is still needed, even if the client has diarrhea.

⚠️Holding the medication would worsen encephalopathy symptoms like confusion.

💧While fluid replacement is important, it does not replace the primary treatment objective of lowering ammonia.

📋Loose stools are an expected effect, not a reason to stop treatment unless excessive dehydration occurs.

📌Core Message

Lactulose should be continued despite diarrhea to reduce high ammonia levels in hepatic encephalopathy.

Answer 6

Correct Answers:

Upper mid abdominal pain described as gnawing and burning.

Rationale :

🔥This type of epigastric pain, often gnawing or burning, is classic for peptic ulcer disease (PUD).

⏱️The pain typically worsens when the stomach is empty and may be relieved by eating or antacids.

💊Antacid use suggests self-treatment but isn't diagnostic without pain details.

🌶️Spicy foods and diarrhea are more characteristic of irritable bowel syndrome (IBS) or gastroenteritis.

📉Weight loss can occur but is nonspecific to PUD alone.

📌Core Message

Burning epigastric pain is the hallmark symptom of peptic ulcer disease.

Answer 7

Correct Answers:

Restrict physical activities.

Rationale :

🏃‍♂️After transurethral needle ablation (TUNA), patients should avoid strenuous activity to prevent bleeding or complications.

💉Hematuria is expected and only concerning if it becomes bright red or heavy, not pink-tinged.

💨Incentive spirometry is unnecessary unless there are respiratory risks.

💧Monitoring urine output is important but reduced stream is an expected and temporary outcome.

📌Core Message

After TUNA, patients should limit physical activity to reduce risk of bleeding.

Answer 8

Correct Answers:

Risk for injury related to effects of thrombolysis.

Rationale :

💉Thrombolytic therapy significantly increases the risk of bleeding, especially intracranial or internal hemorrhage.

⚠️This makes injury prevention the top nursing priority after an MI in clients receiving thrombolytics.

💬Other concerns like activity or knowledge are valid but not life-threatening.

👃Respiratory issues are not a common direct effect of thrombolytic agents.

📋The nurse must vigilantly monitor for signs of bleeding and minimize invasive procedures.

📌Core Message

After thrombolysis, the priority concern is injury risk due to bleeding.

Answer 9

Correct Answers:

High-pitched sound heard upon inspiration.

Rationale :

🎧A high-pitched inspiratory sound suggests laryngeal stridor, a possible sign of airway obstruction, and needs immediate attention.

🧵Post-op pain, localized incision swelling, and mild tachycardia are expected findings.

🔥Severe pain should be addressed, but does not take precedence over potential respiratory compromise.

📋Airway assessments always take top priority in post-surgical patients.

📌Core Message

Inspiratory stridor signals airway obstruction and requires immediate intervention.

Answer 10

Correct Answers:

Fatigue.

Rationale :

💤Fatigue is a key symptom of left ventricular dysfunction due to decreased cardiac output and oxygen delivery.

🦵Edema and hepatomegaly are more associated with right-sided heart failure.

💁‍♂️Jugular vein distension also suggests right-sided or biventricular failure.

📋Fine rales and wheezing indicate pulmonary congestion, aligning with left-sided failure.

📌Core Message

Fatigue is a hallmark of left ventricular dysfunction due to low cardiac output.

2 :
A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

3 :
The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

4 :
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

6 :
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

7 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

8 :
The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

9 :
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

10 :
An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

2 : A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

3 : The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

4 : The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

6 : The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

7 : A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

8 : The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

9 : The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

10 : An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

2 :
A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

3 :
The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

4 :
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

6 :
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

7 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

8 :
The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

9 :
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

10 :
An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?