A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client’s bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?

To help the nurse validate the client’s reports of pain

To increase positive pressure in the chest

To assist the client with ADLS

To modify the client’s perception of pain

Answer and Explanation

The Correct Answer is C

A. To help the nurse validate the client’s reports of pain

This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.

B. To increase positive pressure in the chest

This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.

C. To assist the client with ADLs (Activities of Daily Living)

This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.

D. To modify the client’s perception of pain

This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.

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Correct Answer is C

Explanation

A. "Skeletal traction has less risk for infection than skin traction."

This statement is not accurate. Both skeletal and skin traction carry some risk of infection, but the risk factors and considerations are different for each. Skeletal traction involves pins or wires directly inserted into the bone, and while the risk of infection is present, it is not necessarily lower than that of skin traction.

B. "Clients in skin traction have more mobility than those in skeletal traction."

This statement is not accurate. Skeletal traction, involving the use of weights and pins or wires inserted into the bone, tends to provide more stable immobilization. Skin traction, which relies on external devices applied to the skin's surface, may allow for some limited mobility but is generally not as effective as skeletal traction.

C. "Skeletal traction is better than skin traction for reducing a fracture."

This is the correct statement. Skeletal traction is often more effective in providing a stable and controlled environment for reducing and immobilizing fractures.

D. "Clients in skin traction have more discomfort than those in skeletal traction."

This statement is not necessarily accurate. Discomfort can vary depending on the individual, the type of fracture, and other factors. Both skeletal and skin traction may cause some discomfort, and it's important to assess and manage the client's pain appropriately in either case.

A. Remind the client to tell the nurse when he has to urinate B. Use adult diapers to prevent frequent clothing changes. C. Take the client to the bathroom on an every-2-hr schedule. D. Request a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

A. Remind the client to tell the nurse when he has to urinate.
Reminding the client may not be effective, as individuals with dementia may have difficulty expressing their needs or may forget to communicate when they need to use the bathroom. It relies on the client's ability to remember and communicate.

B. Use adult diapers to prevent frequent clothing changes.
While adult diapers can be part of a comprehensive plan for managing incontinence, they should not be the sole intervention. Relying solely on diapers does not address the underlying causes of incontinence and may not promote optimal dignity and quality of life.

C. Take the client to the bathroom on an every-2-hr schedule.
This is the correct choice. Taking the client to the bathroom on a regular schedule (timed voiding) is a proactive approach to managing urinary incontinence in individuals with dementia. It helps reduce the likelihood of accidents by ensuring regular opportunities for toileting.

D. Request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters are generally not recommended for managing routine urinary incontinence due to the associated risks, including infection. Catheters should be used judiciously and based on medical necessity.

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A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client’s bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

Correct Answer is C

Explanation

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Correct Answer is C

Explanation

A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck’s traction. Which of the following actions should the nurse take?

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A client who has metastatic bone cancer tells the nurse, “I want to go home to die.” The client’s family is concerned about meeting the client’s care needs at home. Which of the following actions should the nurse take?

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