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 D

Explanation

A. Drink carbonated beverages.

Carbonated beverages may cause bloating and gas, which can be uncomfortable for individuals with COPD. It's generally advisable to choose non-carbonated and non-caffeinated beverages.

B. Decrease fiber intake.

Decreasing fiber intake is not a recommended approach for individuals with COPD. Fiber is important for digestive health and overall well-being. A balanced diet, including adequate fiber, is generally encouraged.

C. Use bronchodilators after meals.

The timing of bronchodilator use is typically based on a schedule or as needed for symptom control, rather than being specifically linked to mealtime. It's important to follow the healthcare provider's instructions regarding the use of bronchodilators.

D. Increase protein intake.

Increasing protein intake is an appropriate nutritional recommendation for individuals with COPD. Protein is important for maintaining respiratory muscle strength and overall health.

A. “Use sugar-free gum if you experience a metallic taste in your mouth.” B. “Drink fluids at mealtime to prevent early satiety.” C. “Foods that are higher in fat can help nausea.” D. “Raw fruits and vegetables will be easier for your body to digest.”

Correct Answer is A

Explanation

A. “Use sugar-free gum if you experience a metallic taste in your mouth.”

This is the appropriate choice. Chemotherapy can cause a metallic taste in the mouth, and using sugar-free gum or candies can help alleviate this taste disturbance.

B. “Drink fluids at mealtime to prevent early satiety.”

This statement is not advisable. Drinking fluids at mealtime may lead to early satiety, making it challenging for the client to consume adequate nutrition. It is generally recommended to drink fluids between meals.

C. “Foods that are higher in fat can help nausea.”

This statement is not accurate. High-fat foods may exacerbate nausea for some individuals undergoing chemotherapy. The focus during periods of nausea is often on easily digestible, low-fat, and bland foods.

D. “Raw fruits and vegetables will be easier for your body to digest.”

This statement is not accurate. Raw fruits and vegetables may be harder to digest, and during chemotherapy, the digestive system can be sensitive. It is generally recommended to choose cooked or processed fruits and vegetables for easier digestion.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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