The physician inserted a chest tube drainage to Mr. Alda in order to help re-expand the lungs. Which of the following should you prepare FIRST as a nurse in case of emergency when the tube is accidentally disconnected?

Correct Answer: A

Rationale: Correct Answer: A - sterile clamps Rationale: 1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space. 2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space. 3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection. 4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation. Summary of other choices: B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space. C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube. D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.

Correct Answer: C

Rationale: The correct action in this scenario is to choose option C: put a line across the sentence, make the correction over it, and sign. This method is recommended because it maintains the integrity of the original record by showing what was initially written and clearly indicating the correction. By crossing out the error, making the correction, and signing the entry, the nurse acknowledges and takes responsibility for the mistake while ensuring the accuracy and transparency of the documentation. Option A is incorrect as crossing the error many times can make the note illegible and may not clearly indicate the correction. Option B is incorrect because using correction fluid can make the note messy and may raise suspicions of tampering with the record. Option D is incorrect as erasing with a rubber eraser can damage the document and also raise concerns about the validity of the information. In summary, option C is the best choice as it allows for a clear and professional correction without compromising the integrity of the progress notes.

Correct Answer: D

Rationale: The correct answer is D: advocacy. Advocacy involves actively supporting and promoting the welfare and rights of the patient. Nurses advocate for their patients by ensuring their health, safety, and personal rights are upheld. This ethical principle goes beyond just fulfilling responsibilities or being accountable for one's actions. Responsibility (A) focuses on duties and tasks, accountability (B) is about being answerable for one's actions, and confidentiality (C) pertains to maintaining patient privacy. In this context, advocacy is the most appropriate choice as it encompasses actively working to protect and promote the best interests of the patient.

Correct Answer: C

Rationale: The correct answer is C: Group A beta-hemolytic Streptococcus (GAS). GAS is the most likely organism responsible for this presentation, known as acute bacterial tonsillitis. GAS commonly causes symptoms such as throat pain, odynophagia, fever, tonsillar enlargement with exudates, and cervical lymphadenopathy. Streptococcal pharyngitis is a common bacterial infection of the throat caused by GAS. The other options are less likely as Streptococcus pneumoniae typically causes pneumonia and Haemophilus influenzae is associated with respiratory tract infections. Epstein-Barr virus (EBV) commonly causes infectious mononucleosis, which presents with different symptoms than those described in the question.

Correct Answer: D

Rationale: The correct answer is D, Broad opening. Nurse Rica should use this communication technique to encourage the patient to freely express themselves without leading or interrupting. This technique helps build rapport and trust, setting a positive tone for the conversation. A: Clarifying may be too direct and might make the patient feel pressured. B: Challenging can create defensiveness and hinder open communication. C: Restating may not be as effective in initiating a conversation as broad opening. In summary, broad opening allows for a more open and relaxed conversation, fostering a conducive environment for effective communication with the patient.

Correct Answer: B

Rationale: The correct answer is B: Administer opioid analgesics to alleviate abdominal pain and discomfort. Opioid analgesics are effective in managing severe pain associated with malignant bowel obstruction. By providing adequate pain relief, the patient's comfort and quality of life can be significantly improved. Choice A is incorrect because initiating bowel rest and maintaining the patient in a semi-Fowler's position may not effectively address the severe pain and discomfort experienced by the patient. Choice C is incorrect as surgical intervention in this scenario may not be appropriate or feasible due to the advanced stage of cancer and the presence of malignant bowel obstruction. Choice D is incorrect as antiemetic medications primarily target nausea and vomiting, which may not be the primary symptoms of concern in this case. Focusing on pain management should be the priority.

Correct Answer: D

Rationale: The correct answer is D: Temporal lobe. Memory and learning are primarily associated with the temporal lobe, specifically the hippocampus. Damage to this area due to stroke can lead to memory loss and impaired learning capacity. Frontal lobe (A) is involved in decision-making and problem-solving. Parietal lobe (B) is responsible for sensory processing. Occipital lobe (C) is related to visual processing. Therefore, the temporal lobe is the most likely site of brain damage in this scenario based on the symptoms presented.

Correct Answer: A

Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.

Correct Answer: A

Rationale: The correct answer is A: Anterior uveitis. This condition presents with redness, pain, and photophobia due to inflammation of the uveal tract. Ciliary injection, corneal edema, and mid-dilated pupil with fixed reaction to light are classic signs of anterior uveitis. The other choices can be ruled out based on specific findings: B: Acute angle-closure glaucoma would present with a high intraocular pressure, not fixed dilated pupil. C: Endophthalmitis typically presents with severe pain, hypopyon, and vitreous inflammation. D: Corneal abrasion would not cause ciliary injection or fixed dilated pupil.