A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

'It is unnecessary for you to go to the restroom at this time."

'I can assist you to the bathroom and back to bed."

'I cannot assist you at this time, please wait until I finish what I’m doing”.

'You cannot go to the bathroom.'

Answer and Explanation

The Correct Answer is B

Chest tubes are inserted to drain ﬂuid, blood, or air from the pleural space, which is the space between the lung and the chest wall. It is important to ensure that the chest tube is secured properly and the drainage system is functioning properly before the patient is ambulated. Additionally, the patient may experience discomfort or pain during ambulation, so it is important to assess and manage the patient's pain before and after ambulation.

Option A is not appropriate because it disregards the patient's need to use the restroom and may make the patient feel helpless or dependent.

Option c is not appropriate because it does not address the patient's request for assistance and may make the patient feel neglected or uncared for.

Option d is not appropriate because it is a directive statement that does not take into account the patient's autonomy or individual needs. It is important to involve the patient in the decision-making process and provide appropriate care based on their individual needs and preferences.

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Correct Answer is B

Explanation

Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with ﬂuid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.

Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.

Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.

A. Bicycle safety B. Drug and gun safety C. Use of blankets, pillows, and stuﬀed animals in the crib D. Correct placement of car seats E. Never leaving infant unatended in the bathtub

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

Explanation

Use of blankets, pillows, and stuﬀed animals in the crib: It is important to educate parents about the risk of suﬀocation associated with soft objects in the crib. Infants should always sleep on their back in a crib with a firm matress and no loose bedding or soft objects.
Correct placement of car seats: Properly installed car seats can help prevent serious injury or death in the event of a car accident. It is important to teach parents how to properly install car seats and use them correctly.
Never leaving infant unatended in the bathtub: Drowning is a leading cause of death in young children, and infants can drown in just a few inches of water. It is important to remind parents to never leave their infant unatended in the bathtub, even for a moment.

Therefore, options c, d, and e are the most important topics to include when discussing safety with parents of infants. Options a and b may be important topics to discuss with older children, but they are not relevant to infants.

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A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

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Naxlex Comprehensive Predictor Exams

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

Correct Answer is B

Explanation

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topics would be most important to include: (Select Al That Apply)

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

Explanation

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