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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Eating yogurt can help decrease gas odor that I have."
This is the correct choice. Yogurt contains probiotics, which can contribute to a healthy balance of bacteria in the digestive system, potentially reducing gas odor associated with a colostomy.
B. "I should eliminate pasta from my diet so that I don’t have as many loose stools."
This statement is incorrect. Pasta, as a general rule, is not associated with causing loose stools. Dietary adjustments should be individualized, and specific triggers for loose stools vary among individuals.
C. "My largest meal of the day should be in the evening."
While meal timing can vary based on personal preferences and lifestyle, there is no strict rule that the largest meal must be in the evening. It depends on individual habits and dietary needs.
D. "Carbonated beverages can help control odor."
This statement is incorrect. Carbonated beverages are not typically associated with controlling odor related to a colostomy. In fact, they may contribute to increased gas production, potentially exacerbating odor issues.
Correct Answer is D
Explanation
Correct answer: D
A. "Use mineral oil to relieve constipation.": Mineral oil is not recommended during pregnancy because it can interfere with the absorption of fat-soluble vitamins (A, D, E, K).
B. "Drink 1 liter of water daily to decrease constipation.": While hydration is important, 1 liter of water is insufficient. Pregnant clients are advised to drink more, typically around 2-3 liters daily, to help with digestion and prevent constipation.
C. "Use an enema when constipation occurs.": Enemas are generally not recommended during pregnancy without consulting a healthcare provider, as they may stimulate uterine contractions.
D. “Eat an apple to help with constipation.”Apples are high in fiber, which helps to promote bowel regularity and prevent constipation, making them a healthy option for managing constipation during pregnancy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.