The nurse is assisting with the removal of a client’s chest...

The nurse is assisting with the removal of a client’s chest tube. Which of the following actions should the nurse take? Select all that apply.

A. Ensure the client is given an analgesic 30-60 minutes before tube removal
B. Instruct the client to breathe in, hold it, and bear down while the tube is being removed
C. Place the client in the Trendelenburg position
D. Prepare a sterile airtight petroleum jelly gauze dressing
E. Provide the health care provider with sterile suture removal equipment

Correct Answer: A,B,D,E

Rationale: Analgesics reduce pain, Valsalva maneuver (bear down) prevents air entry, petroleum gauze seals the site, and suture equipment is needed. Trendelenburg is not indicated for chest tube removal.

You may also like to solve these questions

The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.

A. Advising measles vaccination for susceptible family members
B. Applying calamine lotion to reduce itching
C. Placing a tracheostomy tray at the bedside
D. Placing the client in a negative pressure isolation room
E. Using an N95 respirator mask during client contact

Correct Answer: A,D

Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).

The nurse is talking with a client who has human immunodeficiency virus (HIV). Which of the following statements by the client would indicate a correct understanding of the condition? Select all that apply.

A. I should receive the influenza vaccine every year
B. I will ask my roommate to clean the cat litter box for me
C. I should ask for my steak to be cooked thoroughly with no pink inside
D. I can eat the raw vegetables I grew in my garden if my HIV viral load is undetectable
E. I will use bottled water when brushing my teeth if I travel to an area with poor sanitation

Correct Answer: A,B,C,E

Rationale: Flu vaccine, avoiding cat litter (toxoplasmosis risk), thorough cooking, and bottled water in unsanitary areas reduce infection risk in HIV. Raw vegetables pose a risk, even with undetectable viral load.

The nurse is talking with a client with unilateral facial paralysis. Which of the following statements by the client would require follow-up? Select all that apply.

A. I may chew food on either side of my mouth because it does not hurt
B. I need to use my fingers to close my eyelid after instilling eye drops
C. I should prepare meals that include soft, high-calorie foods
D. I will place tape on my affected eyelid before I go to sleep
E. I will put ice on the affected side of my face when it hurts

Correct Answer: A,E

Rationale: Chewing on the affected side risks injury due to impaired sensation, and ice may worsen symptoms in conditions like Bell’s palsy. Closing the eyelid, taping at night, and soft foods are appropriate for facial paralysis management.

Following visitation, the nurse observes a client's wife sitting alone crying. When approached, the wife states, 'I'm so worried about him.' The best response by the nurse is:

A. Are you worried about him being in the hospital?'
B. Tell me what is worrying you.'
C. Would you like to talk with the social worker assigned to your husband?'
D. Would you like to talk with your husband's doctor?'

Correct Answer: B

Rationale: Tell me what is worrying you' encourages the wife to express her concerns, facilitating support. Other responses assume causes or defer to others prematurely.

The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?

A. Administer the prescribed as-needed milk of magnesia
B. Ask dietary services to add more fruits and vegetables to the client’s tray
C. Notify the registered nurse
D. Perform a focused abdominal assessment

Correct Answer: D

Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.