After administering an injection, the nurse observes bleeding at the site. In what sequence should the nurse perform these actions? (Arrange with the first step on top and the last step on the bottom.)

Retract the needle into the syringe.

Place syringe in a puncture-resistant container.

Apply an adhesive bandage over the injection site.

Remove disposable exam gloves.

Answer and Explanation

The Correct Answer is A,B,D,C

Choice A: Retracting the needle into the syringe should be done before safely disposing of the syringe.

Choice B: Placing the syringe in a puncture-resistant container is the second step to ensure safe disposal of sharp objects.

Choice C: Applying an adhesive bandage over the injection site is the final step to address the bleeding and protect the site.

Choice D: Removing disposable exam gloves is the next step to prevent any contamination.

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Correct Answer is A

Explanation

Choice A: Fluctuation with respiration in the water-seal chamber of the chest drainage system is a normal and expected finding for a client with a chest tube in place. It indicates that the system is functioning correctly and allows for the removal of air or fluid from the pleural space during inspiration and expiration.

Choice B: The condition of the dry gauze dressing over the insertion site is important for monitoring any potential signs of infection or bleeding but does not directly relate to the functioning of the chest tube.

Choice C: No bubbling in the suction chamber of the Pleur-Evac system may indicate that the suction pressure is not adequately transmitted to the chest tube or that there is an issue with the system's seal. This finding is not within normal limits and should be addressed.

Choice D: The presence of serous fluid in the drainage chamber of the Pleur- Evac system is expected and indicates that drainage from the pleural space is occurring. However, the key assessment for proper chest tube function is the fluctuation in the water-seal chamber with respiration.

A. Bread B. Beef broth C. Ketchup D. Ice cream.

Correct Answer is C

Explanation

Choice A: Bread is generally considered a suitable food choice for individuals with cholelithiasis and is not typically associated with exacerbating symptoms or gallstone formation.

Choice B: Beef broth is a liquid and does not contain the same types of fats and cholesterol that can contribute to gallstone formation. It is not typically a concern for individuals with cholelithiasis.

Choice C: Ketchup is often high in sugar and can be made with vinegar, which may exacerbate symptoms in some individuals with cholelithiasis. It is advisable to omit or limit foods high in sugar and vinegar-based condiments.

Choice D: Ice cream, while high in fat, is generally tolerated by most individuals with cholelithiasis unless they experience specific dietary sensitivities. It is not typically recommended to omit ice cream from the diet unless advised by a healthcare provider.

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After administering an injection, the nurse observes bleeding at the site. In what sequence should the nurse perform these actions? (Arrange with the first step on top and the last step on the bottom.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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