The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?

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Question 1 of 5

The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?

Correct Answer: A

Rationale: The nurse should examine the entire system and tubing for air leaks when observing vigorous bubbling in the water-seal chamber of a chest-drainage system. Vigorous bubbling indicates that there is air escaping from the system, which can lead to suboptimal drainage and potential complications. By identifying and correcting any air leaks, the nurse can ensure the chest-drainage system functions effectively, allowing for proper drainage and the prevention of complications such as pneumothorax. Lowering the level of suction or asking the patient to cough forcefully would not address the underlying issue of air leaks and may not resolve the problem effectively.

Question 2 of 5

Immunity to a disease after recovery is possible because the first exposure to the pathogen has stimulated the formation of which of the following?

Correct Answer: C

Rationale: Immunity to a disease after recovery is possible because the first exposure to the pathogen has stimulated the formation of memory cells. Memory cells are a type of immune cell that "remembers" the specific pathogen encountered during the initial infection. When the same pathogen tries to infect the individual again, these memory cells quickly recognize the pathogen and mount a faster and stronger immune response, leading to a quicker recovery and preventing the person from getting sick again from the same pathogen. This immune memory is the basis of acquired immunity, providing long-lasting protection against future infections by the same pathogen.

Question 3 of 5

A patient who was walking in the woods disturbed a beehive, was stung, and was taken to the emergency department immediately due to allergies to bee stings. Which of the ff. symptoms would the nurse expect to see upon admission of this patient? i.Pallor around the sting bites iv. Retinal hemorrhage ii.Numbness and tingling in the extremities v. Tachycardia iii.Respiratory stridor vi. Dyspnea

Correct Answer: B

Rationale: The nurse would expect to see respiratory stridor (iii), tachycardia (v), and dyspnea (vi) upon admission of the patient who was stung by a bee, particularly if the patient has allergies to bee stings. These symptoms are indicative of an allergic reaction, which can progress to anaphylaxis in severe cases. Symptoms such as pallor around the sting bites (i), retinal hemorrhage (iv), and numbness and tingling in the extremities (ii) are not typically associated with an allergic reaction to a bee sting.

Question 4 of 5

Which of the following would the nurse evaluate as laboratory data that support the occurrence of AIDS?

Correct Answer: D

Rationale: The nurse would evaluate 200 CD 4+ cells as laboratory data that support the occurrence of AIDS. In patients with AIDS, there is a significant decrease in the CD4+ T-lymphocyte count, typically falling below 200 cells/mm³. This low CD4+ cell count increases the risk of opportunistic infections and indicates severe immune suppression, which is characteristic of AIDS. A CD4+ count of 200 or less is an important criterion for the diagnosis of AIDS according to the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines.

Question 5 of 5

A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery-this will go away on its own". In considering her response to the client, the nurse must depend on the ethical principle of:

Correct Answer: C

Rationale: The ethical principle most relevant in this situation is autonomy. Autonomy refers to a person's right to make decisions about their own care and treatment. In this case, the client is expressing her wish to avoid surgery and believes her condition will improve on its own. It is important for the nurse to respect the client's autonomy and involve her in the decision-making process regarding her treatment. The nurse should provide information, support, and guidance to help the client make an informed decision that aligns with her values and preferences. While the nurse can provide education and encourage the client to consider the physician's recommendation, ultimately the decision should respect the client's autonomy.

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