Extract:

Question 1 of 5

The nurse is caring for a client with a history of peptic ulcer disease who is experiencing hematemesis. Which of the following interventions is the highest priority?

Correct Answer: B

Rationale: Inserting a nasogastric tube is the priority to assess and manage active bleeding in hematemesis.

Question 2 of 5

After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client's care?

A. Clamp the urinary appliance at night. B. Empty the urinary appliance when one-third full. C. Administer prophylactic antibiotics. D. Change the urinary appliance daily.

Correct Answer: B

Rationale: Emptying the appliance when one-third full prevents urine stasis, reducing infection risk.

Question 3 of 5

A postoperative client has a Jackson-Pratt drain. Which finding should the nurse report immediately?

A. Clear, serous drainage. B. Bright red drainage of 50 mL in 2 hours. C. Slight swelling around the drain site. D. Drainage with a foul odor.

Correct Answer: B

Rationale: Bright red drainage suggests active bleeding, a serious complication requiring immediate reporting.

Question 4 of 5

The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.

A. Explain the procedure to the client. B. Obtain a 3-mL syringe with a 1/2-inch needle for the injection. C. Mark the test area to locate it for reading 48 to 72 hours after injection. D. Bunch up the skin and insert the needle with the needle bevel facing downward. E. Cleanse the injection site on the lower dorsal surface of the forearm with alcohol and allow it to dry. F. Ask the client about a history of receiving a positive purified protein derivative (PPD) reaction.

Correct Answer: A,C,E,F

Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.

Question 5 of 5

The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?

A. Continuous bubbling in the water seal chamber. B. Absence of tidaling in the water seal chamber. C. Fluctuation of fluid in the drainage tube with respiration. D. No drainage in the collection chamber.

Correct Answer: C

Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.