A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Monitor for at least 150 mL of drainage every hour.

Clamp the tube for 30 min every 8 hr.

Pin the tubing to the client's bed sheets.

Replace the unit when the drainage chamber is full.

Answer and Explanation

The Correct Answer is A

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

The nurse should recommend the pneumococcal vaccine to the client, as this is recommended for all adults over the age of 65 to prevent pneumococcal disease. Choice A is incorrect because the tuberculosis vaccine is not routinely given to adults in the United States. Choice B is incorrect because the HPV vaccine is recommended primarily for young adults to prevent HPV-related cancers. Choice C is incorrect because the MMR vaccine is recommended for children, and most adults have already received it. Choice A is not correct because the tuberculosis vaccine is not routinely given to adults in the United States.

A. Diaphoresis B. Pupillary dilation C. Chest pain D. Hypotension

Correct Answer is D

Explanation

Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.

Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.

Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .

Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.

View Question and Answer

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

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is reinforcing teaching about disease prevention with an older adult client. Which of the following immunizations should the nurse recommend to the client?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has suspected appendicitis. What finding should the nurse prioritize to report to the provider?

A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?

nurse identify as potentially causing a false-positive result?

A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?

A nurse is reviewing laboratory values for a client who is receiving long-term NSAID therapy for rheumatoid arthritis. Which of the following values should the nurse report to the provider?