a small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs what should the nurse do

NCLEX-PN

Nclex Questions Management of Care

1. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?

A. Consider it a normal finding.
B. Check the system for leaks.
C. Clamp the chest tube.
D. Change the drainage system.

Correct answer: A

Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.

2. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?

A. Unplug the bed's power source.
B. Remove the client from the bed immediately.
C. Notify the biomedical department at once.
D. Turn off the oxygen.

Correct answer: A

Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.

3. What is the 24-hour day-night cycle known as?

A. circadian rhythm
B. infradian rhythm
C. ultradian rhythm
D. non-REM rhythm

Correct answer: A

Rationale: The correct answer is circadian rhythm. Circadian rhythm refers to the rhythmic repetition of patterns that occur approximately every 24 hours, regulating various biological processes related to the day-night cycle. Infradian rhythm, which is longer than 24 hours, and ultradian rhythm, which is shorter than 24 hours, are not the correct terms for the 24-hour cycle. Non-REM rhythm does not specifically relate to the 24-hour day-night cycle, making it an incorrect choice.

4. Which of the following statements by a client indicates adequate understanding of preparation for a lipoprotein fractionation test?

A. "I cannot eat or drink after midnight."?
B. "I cannot eat for 12 hours before the test."?
C. "I need to limit my fluid intake."?
D. "I need to ingest a lipid solution."?

Correct answer: B

Rationale: The correct statement regarding preparation for a lipoprotein fractionation test is that the client cannot eat for 12 hours before the test. It is important to note that the client can drink an unrestricted amount of water. Limiting fluid intake is not necessary for this test. There is no need for the client to ingest a lipid solution as part of the preparation. Therefore, the other choices are incorrect.

5. What is the role of an incident report in risk management?

A. To provide liability protection.
B. To provide data for analysis by a risk manager to determine how future problems can be avoided.
C. To discipline staff for errors.
D. All of the above.

Correct answer: B

Rationale: The correct answer is B. Incident reports play a crucial role in risk management by providing data for analysis to prevent future problems. They are not primarily for liability protection (A) or disciplining staff (C). Therefore, choice B is the most appropriate answer. Choosing option D is incorrect because incident reports do not solely exist for all the mentioned purposes, but primarily to provide data for analysis and preventive actions.