The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.

Monitor collection container and replace when full.

Encourage frequent use of the incentive spirometer.

Assess area around chest tube for subcutaneous emphysema.

Keep tubing loosely coiled below the level of the chest.

Verify air bubbling present in the water seal chamber.

Answer and Explanation

Correct Answer : A,B,C,D

A. Monitor collection container and replace when full: The nurse should monitor the collection container to ensure it doesn't become full, as this could cause backflow into the pleural cavity. Replacing it when full is essential to maintain proper drainage.

B. Encourage frequent use of the incentive spirometer: Using the incentive spirometer helps prevent atelectasis and pneumonia by promoting lung expansion. It is important for postoperative recovery to maintain good respiratory function.

C. Assess area around chest tube for subcutaneous emphysema: Subcutaneous emphysema can occur if air leaks into the tissues around the chest tube. The nurse should check for this condition as it could indicate complications like an air leak or pneumothorax.

D. Keep tubing loosely coiled below the level of the chest: The tubing should be positioned below the chest to facilitate gravity drainage. Keeping it loosely coiled ensures that fluid and air drain efficiently without backflow.

E. Verify air bubbling present in the water seal chamber: Continuous bubbling in the water seal chamber is not expected and may indicate an air leak. Intermittent bubbling may be normal if the lung is still re-expanding, but ongoing bubbling should be reported, not simply verified.

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Correct Answer is D

Explanation

A. Tacos: Tacos are often spicy and greasy, both of which can relax the lower esophageal sphincter and aggravate GERD symptoms in children by increasing acid reflux episodes.

B. Chocolate milkshake: Chocolate and high-fat dairy both reduce LES pressure and increase gastric acid secretion, worsening reflux. The milkshake also adds volume, which can trigger symptoms.

C. Pizza: Pizza is acidic (due to tomato sauce), high in fat, and often spicy—an unhealthy combination for a child with GERD. It’s one of the most commonly reported reflux-triggering foods.

D. Sugar cookies: Sugar cookies are bland, low in fat, and non-acidic, making them a safe snack choice for children managing GERD symptoms through dietary adjustments.

A. "Hyperglycemia often results in weight loss." B. "Hyperglycemia often presents as increased thirst and urination." C. "Hyperglycemia causes an increased sensation of being hungry." D. "Hyperglycemia causes a headache and flushed, dry skin." E. "Hyperglycemia causes cool and clammy skin."

Correct Answer is ["B","C","D"]

Explanation

A. "Hyperglycemia often results in weight loss." While chronic uncontrolled hyperglycemia, particularly in Type 1 diabetes, can lead to weight loss due to the body breaking down fat and muscle for energy, this is less typical for the acute or early signs of hyperglycemia.

B. "Hyperglycemia often presents as increased thirst and urination." This is a classic symptom of hyperglycemia, polydipsia (increased thirst) and polyuria (increased urination), caused by the body attempting to eliminate excess glucose through urine.

C. "Hyperglycemia causes an increased sensation of being hungry." Hyperglycemia can cause an increased sensation of hunger (polyphagia), which occurs due to insulin resistance or the body’s inability to use glucose properly.

D. "Hyperglycemia causes a headache and flushed, dry skin." A common symptom of hyperglycemia is headache, and flushed, dry skin can occur due to dehydration from excessive urination.

E. "Hyperglycemia causes cool and clammy skin." Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia. Hyperglycemia usually presents with warm, dry skin due to dehydration.

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The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions?

Correct Answer is D

Explanation

Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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