The nurse is caring for a child with chest tubes inserted after heart surgery that are attached to an underwater-seal drainage system. For which reason should the nurse prepare to clamp the chest tubes?
A) The child is coughing.
B) A clot obstructs the tubing.
C) A tube becomes disconnected.
D) Red-stained drainage appears in a tube.
C
Feedback:
If a tube becomes disconnected creating an air leak, clamp the tube close to the child's chest to prevent further air from entering the chest. The chest tube should not be clamped if the child is coughing, a clot is in the tubing, or red-stained drainage appears in the tube.
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The nurse is caring for a female patient who is nursing her 3-month-old infant. What will the nurse instruct the patient to do prior to starting heparin to treat venous thrombosis?
A) "Wait an hour after taking the anticoagulant before feeding the infant." B) "Push fluids to clear the drug from her system before feeding the infant." C) "Find another method of feeding the infant while taking this drug." D) "Continue breast-feeding because heparin does not enter breast milk."
When medicating a client for cancer pain, the nursing goal should be to:
a. avoid the use of narcotics for as long as possible b. give the correct amount of medication in relation to the client's level of pain c. medicate the client within 10 minutes of each request for pain medication d. prevent pain rather than treat it after its occurrence
During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption?
A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur
The perinatal nurse explains to the new nurse that ptyalism is a condition more acute than the normal nausea and vomiting of pregnancy and is often associated with dehydration, hypokalemia, and weight loss
A) True B) False