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.

Nursing Test Bank

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Correct Answer is B

Explanation

Peer-reviewed journal articles undergo a rigorous review process by experts in the field before being published. This process ensures that the information presented is based on sound research methods, accurate data, and relevant evidence. Journal articles are considered reliable sources of information as they are reviewed by experts in the field, and the research findings can contribute to evidence-based practice.

First-hand experience with wound care products: While personal experience can be valuable, it may not always reflect the most up-to-date or evidence-based practices. Individual experiences can be subjective and may not have been subject to rigorous evaluation or research.

Information from a wound care product vendor: Information from a vendor may be biased and focused on promoting their own products. It is important to critically evaluate the information and consider whether it is supported by evidence and aligns with current best practices.

An entry on a nursing blog addressing wound healing: Blog entries can vary in quality and credibility. Not all blogs are written or reviewed by experts, and the information provided may not always be evidence-based or reliable. It is important to critically assess the source, author's qualifications, and references cited in the blog post.

A. "Colostrum provides many important antibodies that the newborn lacks.” B. "Colostrum provides vitamin K, which is an essential nutrient for newborns.” C. "Colostrum contains iron, which is important for a newborn's brain development.” D. "Colostrum contains a natural diuretic that stimulates the newborn to void.”

Correct Answer is A

Explanation

Choice A rationale:

Colostrum, the initial breast milk produced after childbirth, is crucial for a newborn's health because it contains a high concentration of antibodies, also known as immunoglobulins (IgA), which provide passive immunity to the baby. These antibodies are essential because a newborn's immune system is immature and not yet capable of producing its antibodies. IgA antibodies in colostrum help protect the baby against various infections, including respiratory and gastrointestinal illnesses. Therefore, choice A is the correct answer as it accurately reflects the importance of colostrum in providing immune protection for the newborn.

Choice B rationale:

Colostrum does not primarily provide vitamin K. While vitamin K is essential for newborns to prevent bleeding disorders, it is not the primary function of colostrum. Colostrum's primary role is to provide immune protection.

Choice C rationale:

Colostrum does contain trace amounts of iron, but its iron content is not the primary reason for its importance. Iron stores in a newborn's body are typically established during the third trimester of pregnancy, and colostrum is not a significant source of iron for the baby. The primary role of colostrum is to provide antibodies, not iron.

Choice D rationale:

Colostrum does not contain a natural diuretic. Its purpose is not to stimulate the newborn to void. Instead, it focuses on providing immune protection and essential nutrients for the baby's initial growth and development.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding.The mother asks, "Why is colostrum so important for my baby?" Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A home health nurse is caring for a client who has Alzheimer's disease.The client's son is concerned about his mother becoming frustrated.Which of the following interventions should the nurse include?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

A nurse is reinforcing teaching with a client who has active pulmonary tuberculosis.Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN.The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is participating in an interprofessional team meeting for a client.Which of the following information about the client should the nurse include?

A nurse is discussing risk factors for child abuse with members of a parenting group.The nurse should identify which of the following findings as characteristic of perpetrators of child abuse?

A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.Which of the following interventions should the nurse plan to include?