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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

A client with emphysema has been receiving oxygen at 3 L per minute by nasal cannula. The nurse knows that the goal of the client's oxygen therapy is achieved when the client's PaO2 reading is:

Correct Answer: B

Rationale: For clients with emphysema, a PaO2 of 70-80 mm Hg indicates adequate oxygenation without suppressing the respiratory drive.

Question 3 of 5

The nurse is preparing to admit a client from the emergency department with tuberculosis. Which of the following should the nurse anticipate in caring for this client? Select all that apply.

Correct Answer: C, D, E, F

Rationale: Tuberculosis requires airborne precautions, standard precautions, negative airflow rooms, and N95/PAPR use due to respiratory transmission. Fall precautions are not specific, and droplet precautions are incorrect.

Question 4 of 5

A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

Correct Answer: D

Rationale: Serum alpha fetoprotein screening detects neural tube defects, such as spina bifida.

Question 5 of 5

Which obstetrical client is most likely to have an infant with respiratory distress syndrome?

Correct Answer: B

Rationale: Maternal diabetes increases the risk of respiratory distress syndrome in infants due to impaired surfactant production from fetal hyperglycemia.

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