A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?

Ensure 2 cm (0.8 in) of water is in the water seal chamber.

Check the patency of the tubing every 2 hr.

Keep the drainage system above the level of the client's chest.

Empty the collection chamber every 8 hr.

Answer and Explanation

The Correct Answer is A

A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.

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Correct Answer is D

Explanation

A. Varicella vaccine is given at 12–15 months and a second dose at 4–6 years. It is not given at 2 months.
B. Influenza vaccine is recommended annually starting at 6 months of age. It is not given at 2 months.
C. Hepatitis A vaccine is given at 12–23 months, with a second dose 6 months later. It is not given at 2 months.
D. Rotavirus vaccine is routinely given at 2 months and again at 4 months (and possibly 6 months depending on the vaccine type). This is the correct answer.

A. Initiate an IV infusion of lactated Ringer's. B. Place the client in a left lateral position. C. Monitor blood pressure every hour. D. Maintain continuous monitoring of the FHR.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Anticipated Interventions:

Initiate an IV infusion of lactated Ringer's
Place the client in a left lateral position
Maintain continuous monitoring of the FHR

Contraindicated Intervention:

Monitor blood pressure every hour

Rationale:

Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.

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A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

Correct Answer is D

Explanation

A nurse in an antepartum unit is caring for a client. Exhibits For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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