The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

Correct Answer: A

Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure. Explanation of other choices: B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing. C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse. D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.

Correct Answer: C

Rationale: In the case of a client diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH), it is crucial to monitor for hyponatremia (Option C). SIADH is a condition where the body retains water excessively, leading to dilutional hyponatremia due to low sodium levels in the blood. This electrolyte abnormality can result in serious neurological symptoms such as confusion, seizures, and coma if not managed appropriately. Option A (Hypokalemia) and Option B (Hyperkalemia) are unlikely in SIADH unless there are additional underlying conditions or medications affecting potassium levels. Monitoring potassium levels is important in other conditions like renal failure. Option D (Hypernatremia) is also incorrect as SIADH typically leads to low sodium levels, not high. Hypernatremia is more commonly seen in conditions where there is excessive water loss or reduced water intake. Educationally, understanding the electrolyte imbalances associated with specific conditions like SIADH is crucial for nurses and healthcare providers to provide safe and effective care. Monitoring electrolyte levels and recognizing early signs of imbalance are key components of managing patients with conditions affecting fluid and electrolyte balance.

Correct Answer: B

Rationale: The correct answer is B) A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent. This client is the most appropriate to assign to the step-down unit nurse because they have stable ABGs despite being ventilator-dependent, indicating better overall respiratory function compared to the other options. Option A is incorrect because a client on a ventilator with acute respiratory failure and respiratory acidosis requires intensive care and close monitoring of their respiratory status, making them unsuitable for the step-down unit. Option C is incorrect because a new admission client with diabetic ketoacidosis on an insulin drip needs specialized care to manage their metabolic condition, which is beyond the scope of a step-down unit nurse. Option D is incorrect because a client on a ventilator with narcotic overdose and respiratory alkalosis may still require close monitoring and intervention for their overdose, making them more appropriate for the intensive care unit. In an educational context, understanding the rationale behind assigning patients based on their condition and level of care needed is crucial for nurses to prioritize patient safety and optimize outcomes. This scenario highlights the importance of matching patient acuity with nursing expertise and resources available in different units to provide appropriate care.

Correct Answer: A

Rationale: In the context of a client undergoing chemotherapy, it is crucial to monitor for potential acid-base imbalances due to the effects of the treatment on the body's normal physiological processes. Nausea and vomiting can lead to metabolic alkalosis, a condition characterized by an increase in pH levels due to the loss of stomach acid and subsequent retention of bicarbonate. This can be a serious complication that needs immediate intervention to prevent further imbalances. Option A is the correct answer because repeated episodes of nausea and vomiting can signal a potential acid-base imbalance, which requires prompt assessment and intervention by the healthcare team. Options B, C, and D are incorrect because they are not directly related to acid-base imbalances. Complaints of pain associated with exertion could indicate musculoskeletal issues or cardiac problems, failure to eat all food on a breakfast tray may suggest lack of appetite or gastrointestinal issues, and client hair loss during a morning bath is a common side effect of chemotherapy and does not directly relate to acid-base problems. In an educational context, understanding the importance of monitoring for signs and symptoms of acid-base imbalances in clients undergoing chemotherapy is essential for providing safe and effective care. Nursing assistants play a vital role in observing and reporting any changes in a client's condition to the healthcare team to ensure timely interventions and prevent complications.

Correct Answer: B

Rationale: In this scenario, the most appropriate nursing measure for Jane, an obese hypertensive homemaker complaining of continual hunger and lack of energy, would be option B) Discussing the importance of eating breakfast. This choice is correct because starting the day with a balanced breakfast can help regulate blood sugar levels, boost metabolism, and provide sustained energy throughout the day. By emphasizing the importance of eating breakfast, the nurse can address Jane's hunger and lack of energy in a practical and effective manner. Option A) Giving her a list of low-calorie foods may not directly address Jane's specific concerns of hunger and lack of energy. While consuming low-calorie foods can be beneficial for weight management, it may not necessarily address the root cause of her symptoms. Option C) Recommending a strict vegetarian diet is too drastic of a dietary change to implement without further assessment of Jane's current eating habits, preferences, and nutritional needs. It may not be the most suitable recommendation for her individual situation. Option D) Suggesting vitamin supplements may not be the most appropriate initial intervention for Jane. While supplements can be beneficial in certain cases, addressing her dietary habits and meal timing should be the priority before considering additional supplementation. In an educational context, it is crucial for nurses to understand the impact of diet on health outcomes, especially in patients with comorbid conditions like obesity and hypertension. By providing tailored nutritional advice and discussing the importance of specific meal practices like eating breakfast, nurses can support patients like Jane in making sustainable lifestyle changes to improve their health and well-being.