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?

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

Clamp the chest tube every 4 hr.

Place the client in a supine position.

Empty the collection chamber every 8 hr.

Answer and Explanation

The Correct Answer is A

Ensuring the device is kept below the level of the client's chest is important to ensure that the drainage system functions properly by allowing the fluid and air to flow downhill. Placing the device below the level of the chest helps facilitate gravity drainage.

Continuous suction is required for proper functioning of the chest tube drainage system. Clamping the chest tube can disrupt the suction and impede the removal of air or fluid from the pleural space. Only in specific circumstances, such as when changing the drainage system or assessing for air leaks, may the healthcare provider request a temporary clamping of the chest tube.

Positioning the client semi-Fowler's, with the head of the bed elevated, can help promote lung expansion and improve oxygenation. The specific positioning may vary depending on the client's condition and the healthcare provider's recommendations.

The nurse should empty the collection chamber as per the facility's protocol, which typically includes monitoring the drainage and emptying it when it reaches a certain level. Regular emptying of the collection chamber helps maintain proper functioning of the chest tube system and allows for accurate measurement of drainage output.

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Correct Answer is B

Explanation

Headaches are a common side effect of isosorbide dinitrate, especially when initially starting the medication. However, they often improve as the body adjusts to the medication. It is important to reassure the client that the headaches should decrease over time. If the headaches persist or worsen, the client should inform their healthcare provider for further evaluation and possible adjustment of the medication regimen.

The statement about taking the medication on an empty stomach is not relevant to preventing headaches associated with isosorbide dinitrate.

The statement about swallowing the tablet whole does not address the issue of headaches. Chewable isosorbide dinitrate is designed to be chewed or dissolved in the mouth, and swallowing it whole may not provide the intended therapeutic effect.

Discontinuing the medication until the headache goes away is not recommended without consulting the healthcare provider. Abruptly stopping or changing the dose of isosorbide dinitrate can have serious consequences and should only be done under medical supervision.

A. Chadwick's sign B. Chloasma C. Hegar's sign D. Ballottement

Correct Answer is A

Explanation

A. Chadwick’s sign

Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.

Chloasma in (option B) is incorrect because it is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.

Hegar's sign in (option C) is incorrect because it is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.

Ballottement in (option D) is incorrect because it is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.

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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 caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

Correct Answer is A

Explanation

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