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 B

Explanation

A. The ropes are in the center of the wheel grooves.

Having the ropes in the center of the wheel grooves is appropriate and ensures proper alignment within the pulley system. This is not a problem that needs correction.

B. The weights rest against the foot of the bed.

This is the correct choice for correction. Allowing the weights to rest against the foot of the bed can alter the amount of force applied to the skeletal structures and compromise the effectiveness of the traction. The weights should hang freely and move within the pulley system.

C. The weights are equal on each side.

Having equal weights on each side is generally appropriate and helps maintain proper balance in the traction system. This is not a problem that needs correction.

D. The ropes attach securely to the pin.

Secure attachment of the ropes to the pin is essential for maintaining proper traction. This is not a problem that needs correction if the attachment is secure.

A. “I’ll apply ice to my ankle for 20 minutes every hour.” B. “I’ll rewrap my ankle starting from the knee down.” C. “I’ll walk on my ankle for 10 minutes every hour.” D. “I’ll put a heating pad on my ankle at bedtime tonight.”

Correct Answer is A

Explanation

A. "I’ll apply ice to my ankle for 20 minutes every hour."

This is the correct choice. Applying ice for a specified duration (20 minutes) every hour is a standard recommendation for managing swelling and pain associated with an ankle sprain. It helps reduce inflammation and provides relief.

B. "I’ll rewrap my ankle starting from the knee down."

This statement indicates a misunderstanding. When rewrapping an ankle, it should be done from the bottom (proximal) to the top (distal) to provide proper compression. Starting from the knee down is not the correct technique.

C. "I’ll walk on my ankle for 10 minutes every hour."

This statement may indicate a misunderstanding or potential for harm. Immediate weight-bearing or walking on an injured ankle, especially after a sprain, is generally not recommended. Rest is often a key component of initial management.

D. "I’ll put a heating pad on my ankle at bedtime tonight."

This statement may indicate a misunderstanding. Heat is not typically recommended in the initial stages of treating an acute injury like an ankle sprain, as it may increase inflammation. Ice (cold therapy) is usually the preferred modality early on to reduce swelling and pain.

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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 client returns to the surgical unit from the PACU in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup?

Correct Answer is B

Explanation

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

Correct Answer is A

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?

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?

A nurse is assisting with meal planning for a client who has hypothyroidism. The nurse should reinforce with the client that she should increase her daily intake of which of the following nutrients?

A nurse is reinforcing teaching about management of constipation during pregnancy with a group of pregnant clients who are pregnant. Which of the following statements should the nurse include in the teaching?

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?

A nurse is reinforcing teaching with a client who has Crohn’s Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is receiving enteral tube feedings of a diluted formula. Which of the following complications of enteral tube feeding should the nurse identify as a reason to administer diluted feedings to clients?

A client tells the nurse that he suspects that he grinds his teeth at night. Along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?