Extract:

Question 1 of 5

The nurse is involved in preoperative teaching with a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that the purpose of the nurse is to:

Correct Answer: B, C

Rationale: Chest tubes are placed to remove air (pneumothorax) and fluid (hemothorax or pleural effusion) from the pleural space to restore negative pressure and lung expansion. Preventing clots or milking tubes is not their primary purpose.

Question 2 of 5

The nurse is preparing to do tracheostomy care on a client. Which tracheostomy care items should the nurse obtain to perform this procedure?

A. Suction kit and tracheostomy dressing B. Bottle of sterile saline and a tracheostomy care kit C. Bottles of sterile saline and water and a tracheostomy dressing D. Tracheostomy care kit, sterile saline and water, and a suction kit

Correct Answer: D

Rationale: Equipment needed to perform tracheostomy care includes a tracheostomy care kit, sterile water and saline solutions for cleansing and rinsing, and a suction kit for client suctioning. As part of tracheostomy care, the client's airway should be suctioned before cleansing the tracheostomy. New sterile solutions are obtained once per 24 hours, which is often done at the beginning of the workday. A tracheostomy care kit contains the needed supplies for cleaning the tracheostomy and for changing the dressing and holder (trach ties).

Question 3 of 5

When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.

A. Having suction equipment readily available B. Keeping all the lights on in the room at night C. Keeping a padded tongue blade at the bedside D. Assisting the client to ambulate in the hallway E. Monitoring the client closely while showering F. Locking the client's bed in its lowest position

Correct Answer: A,D,E,F

Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.

Question 4 of 5

The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?

A. First maneuver. B. Second maneuver. C. Third maneuver. D. Fourth maneuver.

Correct Answer: C

Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence

Question 5 of 5

A client being treated for a comminuted fractured tibia asks the nurse to explain what a comminuted fracture means. The nurse should give which response?

A. It means the fracture is incomplete. B. It means the bone is partially fractured. C. It means the bone fractured with splintering of the bone into fragments. D. It means the skin or mucous membrane was broken when the fracture occurred.

Correct Answer: C

Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent. A compound fracture, also called an open fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone.