Extract:

Question 1 of 5

Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. 1. The vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5. The exudate phase 6. The convalescence phase

Correct Answer: B

Rationale: The inflammatory response includes the initial injury (4), followed by the vascular phase (1, vasodilation and increased permeability), and then the exudate phase (5, fluid and cell migration). Prodromal (2), incubation (3), and convalescence (6) are not part of the inflammatory process. Thus, B (4,1,5) is correct.

Question 2 of 5

A client with a diagnosis of gout is prescribed indomethacin. The nurse should instruct the client to:

A. Take the medication with food to reduce stomach upset. B. Avoid drinking alcohol. C. Limit fluid intake. D. Take the medication at bedtime only.

Correct Answer: A,B

Rationale: Taking indomethacin with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.

Question 3 of 5

What is the term that is used to describe a healthcare related incident or accident that may have possibly led to client harm?

A. An adverse event B. A root cause C. A healthcare acquired event D. A sentinel event

Correct Answer: A

Rationale: An adverse event is a healthcare-related incident that may have led to client harm, such as medication errors or falls.

Question 4 of 5

A client with a history of liver cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?

A. Hypotension. B. Respiratory distress. C. Hyperkalemia. D. Hypoglycemia.

Correct Answer: B

Rationale: Ascites can compress the diaphragm, leading to respiratory distress, a complication the nurse should monitor for in cirrhosis.

Question 5 of 5

The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.

A. Encourage the client to cough and deep breathe. B. Add water to the suction chamber as it evaporates. C. Keep the collection chamber below the client's waist. D. Clamp the chest tube when the client gets out of bed. E. Tape the connection between the chest tube and the drainage system.

Correct Answer: A,B,C,E

Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.