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. Provide a diet high in protein. B. Provide ibuprofen for retroperitoneal discomfort. C. Monitor intake and output hourly D. Encourage the client to consume at least 2 L of fluid daily

Correct Answer is C

Explanation

A. Provide a diet high in protein.

During the oliguric phase of acute kidney injury (AKI), there is a risk of electrolyte imbalances, including elevated levels of blood urea nitrogen (BUN) and creatinine. Restricting protein intake is often recommended during this phase to manage azotemia and prevent the accumulation of waste products that the kidneys may struggle to excrete.

B. Provide ibuprofen for retroperitoneal discomfort.

Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in AKI. They can further compromise renal function and may contribute to acute tubular necrosis. NSAIDs can also affect renal blood flow, leading to worsening kidney function.

C. Monitor intake and output hourly.

Monitoring intake and output (I&O) is a critical nursing intervention during the oliguric phase of AKI. Hourly monitoring helps assess renal function, fluid balance, and the effectiveness of interventions. It allows for early detection of changes that may require prompt intervention.

D. Encourage the client to consume at least 2 L of fluid daily.

In the oliguric phase of AKI, fluid intake is often restricted to prevent fluid overload. Encouraging excessive fluid intake may contribute to fluid retention and worsen the oliguria. Fluid management is carefully regulated based on the individual client's needs and renal function.

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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

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information 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?

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