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Questions 158

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Question 1 of 5

The nurse caring for a client with closed chest drainage notes that the collection chamber is full.

Correct Answer: D

Rationale: A full collection chamber requires replacing the chest drainage unit to maintain effective drainage and prevent complications like tension pneumothorax.

Question 2 of 5

Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:

Correct Answer: C

Rationale: Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss.

Question 3 of 5

Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?

Correct Answer: C

Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.

Question 4 of 5

When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:

Correct Answer: C

Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.

Question 5 of 5

The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?

Correct Answer: A

Rationale: A diabetic with a foot ulcer is stable and suitable for an LPN, who can perform wound care and monitoring. Heparin infusion (
B), tracheostomy weaning (
C), and T-tube management (
D) require RN-level skills due to complexity and risk.

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