A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Clamp the chest tube every 4 hr.

Place the client in a supine position.

Ensure the device is kept below the level of the client's chest.

Empty the collection chamber every 8 hr.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended, as it can lead to tension pneumothorax by trapping air in the pleural space. Clamping is only done briefly and for specific reasons, such as system checks or before removal.

B. Place the client in a supine position: The supine position can impair lung expansion and hinder drainage from the pleural space. Clients with a chest tube are best positioned in semi-Fowler’s or high-Fowler’s to promote ventilation and facilitate drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the drainage system below chest level promotes gravity-assisted drainage and prevents backflow of air or fluid into the pleural space, which could compromise lung re-expansion.

D. Empty the collection chamber every 8 hr: The collection chamber is not emptied; it is replaced when full. Opening the system introduces infection risk and disrupts the closed drainage system necessary for maintaining negative pressure.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","D","G","H"]

Explanation

Rationale:

• An older adult client is at high risk for delirium due to age-related changes in the brain and reduced physiological reserve. ICU environments and acute illness increase susceptibility in older adults. Age over 65 is a primary risk factor in many validated delirium screening tools.

• Fever and hypotension suggest a systemic infection and possible sepsis, which can impair cerebral perfusion. This can trigger acute confusion or delirium, especially in vulnerable individuals. The combination of infection and low blood pressure disrupts normal brain function.

• Total left hip arthroplasty involves major surgery and potential postoperative complications such as infection or pain. Surgical trauma, anesthesia, and immobility all increase delirium risk. Recent surgery also increases inflammatory cytokine activity affecting cognition.

• Past medical history: Parkinson’s disease is linked to higher delirium risk due to existing neurotransmitter imbalances. The condition often coexists with cognitive decline or medication interactions. Parkinson’s-related brain changes make acute confusion more likely.

• Visual loss without glasses limits sensory input and orientation cues, contributing to perceptual disturbances. Poor vision can lead to misinterpretation of surroundings, promoting hallucinations or paranoia. Environmental disorientation is a key factor in ICU-related delirium.

A. Use an N95 respirator. B. Initiate contact precautions C. Place the child in a room that has a HEPA filtration system. D. Instruct the parents to avoid bringing fresh flowers into the room.

Correct Answer is B

Explanation

Rationale:

A. Use an N95 respirator: N95 respirators are necessary for airborne precautions, such as with tuberculosis or measles. C. difficile is transmitted via contact with contaminated surfaces or stool, not airborne particles, so an N95 is not indicated.

B. Initiate contact precautions: Contact precautions are required for C. difficile because it spreads through direct and indirect contact with contaminated surfaces or stool. Gloves and gowns should be worn, and hand hygiene with soap and water is essential to prevent spore transmission.

C. Place the child in a room that has a HEPA filtration system: HEPA filters are used for airborne pathogens or immunocompromised clients, not for enteric infections like C. difficile. This intervention would not reduce transmission risk in this case.

D. Instruct the parents to avoid bringing fresh flowers into the room: This precaution is typically for neutropenic or immunocompromised clients to reduce exposure to potential fungal spores. C. difficile precautions focus on containment of fecal-oral transmission routes, not environmental fungal sources.

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 contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D","G","H"]

Explanation

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a family practice office routinely reviews clients' immunization status at their annual physical examination visits. For which of the following clients should the nurse recommend a human papillomavirus immunization?

A nurse is caring for a client who has rheumatoid arthritis and is having difficulty with ADLs, such as cooking and eating. The nurse should ensure that the client has a referral to which of the following members of the interprofessional team?

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data. Exhibits Complete the following sentence by using the list of options. The nurse should first plan to dropdown and then dropdown.

A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?

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 reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

A nurse is assisting with the care of a client who has schizophrenia and is actively hallucinating. Which of the following actions should the nurse take?