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 C
Explanation
A. Use a blow dryer on a moderate heat setting to dry the cast after showering.
This is not recommended as using a blow dryer on a cast can cause burns. Instead, the cast should be allowed to air-dry or be dried with a fan.
B. Use a cotton swab to relieve itching under the cast.
Inserting objects, including cotton swabs, under the cast can lead to complications such as infection or skin damage. It is not recommended to insert anything into the cast.
C. Report any worsening or unrelieved pain.
This is the correct instruction. Persistent or increasing pain can indicate complications such as swelling, infection, or neurovascular compromise. It is important for the client to promptly report any changes in pain to healthcare providers.
D. Avoid moving the affected leg.
While it's important to limit movement to allow for proper healing, complete immobilization can lead to joint stiffness and muscle atrophy. Gentle range-of-motion exercises for non-weight-bearing areas may be encouraged, but any specific movement instructions should be provided by the healthcare provider. If movement causes significant pain or discomfort, the client should consult the healthcare provider.
Correct Answer is B
Explanation
A. Electrolyte imbalances
Administering diluted enteral feedings is not typically done to address electrolyte imbalances. Instead, monitoring the electrolyte levels in the patient's blood and adjusting the content of the enteral formula (such as adjusting the concentration of electrolytes) would be more appropriate.
B. Diarrhea
Administering diluted enteral feedings is a strategy that may be employed to prevent or manage diarrhea. High concentrations of nutrients can overwhelm the gastrointestinal tract, leading to diarrhea. Diluting the formula helps reduce the risk of this complication.
C. Constipation
Administering diluted enteral feedings is not typically done to address constipation. Management of constipation is more commonly achieved through adjustments in fiber intake, fluid intake, and medications as needed.
D. Delayed gastric emptying
Administering diluted enteral feedings is not a standard approach for addressing delayed gastric emptying. Instead, adjustments in the rate of enteral feedings or specific interventions for delayed gastric emptying, such as medication or changes in positioning, would be considered.
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