a patient who has a right sided chest tube following a thoracotomy has continuous bubbling in the suction control chamber of the collection device whi

NCLEX-RN

NCLEX RN Prioritization Questions

1. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?

A. Document the presence of continuous bubbling.
B. Notify the surgeon of a possible pneumothorax.
C. Take no further action with the collection device.
D. Adjust the dial on the wall regulator to decrease suction.

Correct answer: C

Rationale: Continuous bubbling in the suction-control chamber of the chest tube collection device is an expected finding and indicates that the suction control chamber is connected to suction. It does not necessarily indicate a large air leak, which would be detected in the water-seal chamber. There is no evidence to suggest a pneumothorax based solely on continuous bubbling in the suction-control chamber. Adjusting the suction level by changing the wall regulator setting is not indicated in this situation, as the amount of suction applied is primarily regulated by the water level in the water-seal chamber and not by the vacuum source. Therefore, the most appropriate action in this scenario is for the nurse to take no further action with the collection device.

2. Which of the following patients is at the greatest risk for a stroke?

A. A 60-year-old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past
B. A 75-year-old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic
C. A 40-year-old female who has high cholesterol and uses oral contraceptives
D. A 65-year-old female who is African American, has sickle cell disease, and smokes cigarettes

Correct answer: A

Rationale: The correct answer is the 60-year-old male who has a combination of significant risk factors for stroke, including atrial fibrillation, a history of a transient ischemic attack (TIA), and obesity. These factors greatly increase his risk of stroke. While other choices may have some individual risk factors, they do not collectively pose as high a risk as the patient described in option A. Option B includes migraines and alcohol consumption but lacks other major risk factors seen in option A. Option C mentions high cholesterol and oral contraceptives, which are risk factors but not as significant as atrial fibrillation and a prior TIA. Option D includes smoking and sickle cell disease but lacks the crucial risk factors present in option A.

3. Following mitral valve replacement surgery, a client develops PVCs. The healthcare provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mg/minute. The IV solution contains 2 grams of Lidocaine in 500 mL of D5W. The infusion pump delivers 60 microdrops/mL. What rate would deliver 4 mg of Lidocaine per minute?

A. 60 microdrops/minute
B. 20 microdrops/minute
C. 30 microdrops/minute
D. 40 microdrops/minute

Correct answer: A

Rationale: To calculate the rate needed to deliver 4 mg/minute of Lidocaine, first, convert 2 grams to milligrams: 2 grams = 2000 mg. Then, set up a ratio between the total amount of Lidocaine (2000 mg) and the total volume of IV solution (500 mL): 2000 mg / 500 mL = 4 mg / x mL. Solving for x, x = 1 mL. Since the infusion pump delivers 60 microdrops per mL, multiplying by 60 microdrops/mL gives the correct rate of 60 microdrops/minute. This rate ensures the desired 4 mg of Lidocaine is delivered per minute. Choices B, C, and D are incorrect as they do not align with the accurate calculation based on the provided information.

4. What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?

A. Decrease the patient's evening fluid intake.
B. Teach the patient how to use the Cred method.
C. Suggest the use of adult incontinence briefs for nighttime only.
D. Assist the patient to the commode every 2 hours during the day.

Correct answer: B

Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.

5. What preparation should be made for a client undergoing a KUB (Kidney, Ureter, Bladder) radiography test?

A. Client must be NPO before the examination
B. Enema should be administered before the examination
C. Medicate the client with furosemide 20 mg IV 30 minutes before the examination
D. No special orders are necessary for this examination

Correct answer: D

Rationale: The correct answer is that no special orders are necessary for a KUB radiography test. It is important to inform the client to remove any clothing, jewelry, or objects that may interfere with the test. Option A is incorrect because there is no need for the client to be NPO before this examination. Option B is incorrect as enemas are not routinely administered prior to a KUB radiography test. Option C is incorrect as there is no need to medicate the client with furosemide before this examination.