A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.
Which of the following information is the priority for the nurse to discuss?

Choosing an agency to provide home physical therapy.

Obtaining an alert system to get help in case of a fall.

Providing information about available transportation resources.

Reviewing information about support groups for individuals who have had a stroke.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Choosing an agency to provide home physical therapy is important, but it is not the priority in this situation. The client's safety and immediate needs should be addressed first.

Choice B rationale:

Obtaining an alert system to get help in case of a fall is the priority for an older adult living alone with left-sided weakness following a stroke. Falls can result in serious injuries, so having an alert system ensures the client can call for assistance promptly, enhancing their safety and well-being.

Choice C rationale:

Providing information about available transportation resources is important for the client's long-term independence and quality of life. However, immediate safety concerns, such as the risk of falls, should be addressed first.

Choice D rationale:

Reviewing information about support groups for individuals who have had a stroke is essential for the client's emotional well-being and social support. However, immediate safety measures, such as fall prevention, take precedence in this scenario.

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Correct Answer is C

No explanation

A. The lung has re-expanded. B. There is a loop of tubing below the drainage system. C. The system is working properly. D. The tubing is partially obstructed by clots.

Correct Answer is C

Explanation

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed

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A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.Which of the following information is the priority for the nurse to discuss?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

Correct Answer is C

Explanation

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A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.
Which of the following information is the priority for the nurse to discuss?