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Questions 164

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Question 1 of 5

The nurse is caring for a client who has a chest tube connected to a wet suction closed chest drainage system. The nurse should recognize the drainage system is working correctly when gentle, continuous bubbling is present in the

Correct Answer: D

Rationale: Gentle, continuous bubbling in the suction control chamber indicates proper suction in a wet suction system. Bubbling in the water seal suggests an air leak, and the collection chamber does not bubble.

Question 2 of 5

The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?

Correct Answer: B

Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.

Question 3 of 5

The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.

Correct Answer: A,C,D,F

Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.

Question 4 of 5

The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?

Correct Answer: C

Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.

Question 5 of 5

A client with cancer of the stomach has a gastric resection. The nurse should tell the client that following surgery:

Correct Answer: B

Rationale: Proteins and vitamins support tissue repair post-gastrectomy. Any food may cause dumping syndrome. High-calorie liquids are too restrictive. High fat delays gastric emptying.

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