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

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

Rationale:

A. A child who was conceived by in vitro fertilization: Children conceived through IVF are typically highly desired and planned for, and families may invest significant emotional and financial resources into their care. This background generally reduces rather than increases the risk of maltreatment.

B. A toddler who has atopic dermatitis: Although chronic conditions can be stressful for caregivers, atopic dermatitis is relatively common and manageable. It does not significantly increase the risk of child abuse or neglect compared to more severe or demanding conditions.

C. An only child: Being an only child does not inherently increase the risk for maltreatment. Risk factors for abuse are more closely associated with caregiver stress, socioeconomic status, substance use, and the presence of physical or cognitive impairments in the child.

D. A school-age child who has cerebral palsy: Children with disabilities like cerebral palsy are at higher risk for maltreatment due to the physical, emotional, and financial stress their care may place on caregivers. These children often require more supervision and support, which can lead to frustration or neglect in high-risk environments.

A. "You should replace your diaphragm every 2 year” B. "You should be refitted for your diaphragm if you have a 10 percent weight fluctuation." C. "You should insert the diaphragm when your bladder is full." D. "You should remove your diaphragm 4 hours after intercourse."

Correct Answer is B

Explanation

Rationale:

A. "You should replace your diaphragm every 2 years": Diaphragms generally need to be replaced every 1 to 2 years, depending on the manufacturer’s guidelines and wear and tear. However, it is more important to be aware of refitting needs related to physiological changes.

B. "You should be refitted for your diaphragm if you have a 10 percent weight fluctuation.": Significant weight changes, usually around 10 to 15 percent, can alter pelvic anatomy and affect diaphragm fit, increasing the risk of contraceptive failure. Therefore, refitting is recommended after notable weight fluctuations.

C. "You should insert the diaphragm when your bladder is full.": The bladder should be empty when inserting the diaphragm to avoid discomfort and ensure proper placement over the cervix. A full bladder can cause displacement and increase the risk of failure.

D. "You should remove your diaphragm 4 hours after intercourse.": The diaphragm should be left in place for at least 6 hours after intercourse to ensure adequate sperm immobilization and contraceptive effectiveness. Removing it too early may increase the risk of pregnancy.

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

A nurse is discussing risk factors for child maltreatment with a newly licensed nurse. Which of the following examples should the nurse include?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is using a diaphragm to prevent pregnancy. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the guardian of a newborn about measures that can be taken to minimize the risk of sudden unexpected infant death (SUID). Which of the following instructions should the nurse include in 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?

A nurse is caring for a client who has a peanut allergy. The client states. "I feel like my throat is closing "Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?

A nurse is assisting in the care of a client who is 4 days postpartum and has endometritis. Which of the following interventions should the nurse anticipate will be included in the plan of care?

A nurse is assisting with the care of a child who has suspected intussusception. Which of the following manifestations is an expected finding?

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablets. Which of the following statements by the client indicates an understanding of the teaching?