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.

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Correct Answer is A

Explanation

The correct answer is choice A, participate in reminiscence therapy with the client. This is an effective intervention for individuals with Alzheimer's disease. It involves encouraging the client to discuss past experiences and events. It has been shown to improve mood, decrease agitation, and increase communication skills. The reminiscence therapy should be individualized and tailored to the client's interests and abilities.

Raising the four side rails on the client's bed is not the correct answer because this could cause harm to the client by restricting their mobility and independence.
Alternating the client's daily routine is not the correct answer because individuals with Alzheimer's disease benefit from a consistent routine, which helps them to feel more secure and less anxious.
Keeping the lights dimmed is not the correct answer because it can be disorienting and confusing for clients with Alzheimer's disease, who need adequate lighting to distinguish their surroundings.

A. Sildenafil B. Metformin C. Omeprazole D. Atorvastatin

Correct Answer is A

Explanation

The nurse should instruct the client to avoid taking medications for erectile dysfunction, such as sildenafil, within 24 hours of taking nitroglycerin due to the risk of severe hypotension.

Reasons why the other options are not answers:

Option B: Metformin is not contraindicated with nitroglycerin.

Option C: Omeprazole is not contraindicated with nitroglycerin.

Option D: Atorvastatin is not contraindicated with nitroglycerin.

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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 long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?

Correct Answer is A

Explanation

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