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Questions 149

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Question 1 of 5

A client in ICU has a chest tube, and the nurse is assessing the chest tube drainage system. The nurse notices intermittent bubbling in the water seal chamber. What action should the nurse take?

Correct Answer: B

Rationale: Intermittent bubbling in the water seal chamber is normal during inspiration/expiration or coughing, indicating a patent system. It should be documented as a normal finding.

Question 2 of 5

The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?

Correct Answer: C

Rationale:
To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.

Question 3 of 5

A client is admitted to the surgical unit following a transurethral prostatectomy (TURP). The nurse administers a B&O suppository to help prevent bladder spasms. The nurse would observe the client for:

Correct Answer: C

Rationale: Belladonna and opium (B&O) suppositories can cause nausea and vomiting as side effects. These are more immediate concerns than dependence or the other symptoms.

Question 4 of 5

The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld

Question 5 of 5

The physician has ordered Dextrose 5% in normal saline for an infant admitted with gastroenteritis. The advantage of administering the infant's IV through a scalp vein is:

Correct Answer: A

Rationale: Scalp veins allow easier access for IV administration in infants, and the site is more accessible for comforting the infant without disturbing the IV line.

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