A nurse is assisting in the care of a client.

Admission Assessment.

1500: Client transferred from postanesthesia care unit, following a left lung lobectomy.

Client alert and oriented to person, place, time,. and situation.

Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest.

Water seal chest tube drainage system has 100 mL sanguineous drainage.

Right lung sounds clear.

Left lung sounds diminished.

For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.

Clamp chest tube when client ambulates.

Report burning pain in chest to provider.

Reinforce dressing around the tube as needed if it loosens.

Strip the tubing twice daily to ensure patency.

Maintain chest tube below the chest.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated.

Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort.

Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.

Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.

Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.

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Correct Answer is B

Explanation

Choice A rationale:

Informing the client that the procedure will take 60 minutes is not a critical action before an esophagogastroduodenoscopy (EGD) The duration of the procedure may vary, but this information is not as essential as other pre-procedure considerations.

Choice B rationale:

The correct action is to "Ensure that the client gave informed consent." Before any invasive procedure like an EGD, it is crucial to confirm that the client has provided informed consent. This ensures that the client understands the procedure, its risks, and benefits, and has the opportunity to ask questions and make an informed decision.

Choice C rationale:

Administering an oral contrast solution is not typically done before an EGD. An EGD involves the insertion of a flexible scope through the mouth into the esophagus, stomach, and duodenum to visualize these structures. Contrast solutions are usually used in other imaging procedures, such as barium swallow studies.

Choice D rationale:

Ensuring that the client's bladder is full is not necessary for an EGD. This requirement may be relevant for other imaging studies, but it does not apply to this procedure. The focus should be on the client's comfort, safety, and informed consent before the EGD.

A. Encourage the client to be assertive. B. Assume responsibility for making the client's decisions. C. Maintain a verbal no-harm contract with the client. D. Limit the client's social interactions.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should encourage the client to be assertive. Dependent Personality Disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. One of the treatment goals is to help the client develop assertiveness skills to reduce their dependence on others. Encouraging assertiveness allows the client to express their needs and make decisions for themselves, which is an essential aspect of their therapeutic journey toward independence.

Choice B rationale:

Assuming responsibility for making the client's decisions would not be appropriate. It would further reinforce the client's dependent behavior and hinder their progress towards independence. The goal of therapy is to promote autonomy and self-reliance, not to perpetuate dependency.

Choice C rationale:

Maintaining a verbal no-harm contract with the client may be necessary in some cases, especially if the client exhibits self-harming behaviors. However, it is not a primary teaching point when educating the caregiver about managing a client with Dependent Personality Disorder. The focus should primarily be on helping the client develop assertiveness and self-reliance.

Choice D rationale:

Limiting the client's social interactions is not an appropriate intervention. Social support can be beneficial for individuals with Dependent Personality Disorder, as it can help them build self-confidence and reduce their excessive reliance on one individual. Isolating the client would not be in their best interest.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy.Which of the following actions should the nurse take prior to the procedure?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder.Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough.Which type of isolation precautions should the nurse initiate for the client?

A nurse is reinforcing teaching about foot care with a client who has type 2 diabetes mellitus.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing care to a client who is immunocompromised.Which of the following should the nurse identify as a possible source of infection?

A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily.The client asks why the nurse is checking his blood glucose level.Which of the following responses should the nurse make?

A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.Which of the following interventions is the nurse's priority?

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus.For which of the following data should the nurse monitor?