A water seal system for chest drainage has been inserted into a patient who suffered chest trauma during a motor vehicle accident
At the beginning of the night shift, the nurse has entered the patient's room to assess the system and the patient's condition. Which of the following assessment findings suggests that the system is operating correctly and the patient is maintaining oxygenation?
A) There is constant bubbling in the water seal chamber.
B) The water level in the water seal chamber increases when the patient inhales.
C) The level in the water seal chamber stays constant throughout the ventilation cycle.
D) The water level reaches the top of the water seal chamber with each breath.
B
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After observing parental behavior that leads the nurse to suspect child abuse, when should the nurse report the abuse?
a. If the parent confesses to child abuse b. If the child admits to being abused c. Whenever maltreatment of a child is suspected d. When the type of abuse can be determined
The nurse is preparing to administer a medication to a patient on a medical-surgical unit. The median lethal dose of the drug is 40 mg, and the median effective dose is 10 mg. The nurse calculates the therapeutic index to be _____
What will be an ideal response?
Which technique should the nurse employ to best assess skin turgor?
a. Examine mucous membranes of the mouth. b. Compare limbs for similar color. c. Pinch a skinfold on chest to assess for tenting. d. Palpate the ankles for evidence of pitting edema.
The nurse on an inpatient psychiatric unit is developing the plan of care for a 17-year-old girl admitted with anorexia nervosa
The client's weight is 40% below normal. She engages in many rituals related to eating, asks to be weighed several times per day, and complains that her access to the bathroom is limited. The nurse develops a contract with her. The purpose of the contract is to do which of the following? A) Provide the client with a feeling of responsibility and control over her behavior B) Provide the therapist with a strategy for client compliance C) Allow the client a tool by which to negotiate behavior D) Provide the nurse with a tool for evaluating the plan of care