Nokea
The healthcare provider is caring for a client with a chest tube. Which intervention is most important to include in the plan of care?
- A. Maintain continuous suction on the chest tube.
- B. Clamp the chest tube during client movement.
- C. Ensure that the chest tube is clamped for at least 8 hours each day.
- D. Keep the collection chamber below the level of the chest.
Correct Answer: D
Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.
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A public health nurse is planning a smoking cessation program for a local community. Which component is most important to include in the program?
- A. information on the health risks of smoking
- B. strategies for coping with withdrawal symptoms
- C. testimonials from former smokers
- D. distribution of nicotine replacement therapy
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is developing a workshop on cancer prevention for a group of adults at a wellness bar. Which recommendation should the nurse include in the workshop?
- A. know the 4 warning signs of cancer
- B. maintain a healthy weight and exercise regularly
- C. refrain from alcohol
- D. obtain at least 6 to 10 hours of sleep per night
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?
- A. Call the pharmacy to determine what medications she is taking
- B. Seek the family's assistance in taking care of the client
- C. Complete a physical and mental exam on the client
- D. Call the adult protective services to obtain emergency nursing home placement
Correct Answer: C
Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.
During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds on to the furniture while refusing any assistance. Which action should the nurse implement?
- A. determine home navigational safety hazards
- B. maintain the client's privacy while in the bathroom
- C. recommend that the client obtain a walker
- D. encourage the client to obtain a medical alert device
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A school nurse is planning a program to address bullying among students. Which strategy is most likely to be effective?
- A. Implementing a zero-tolerance policy for bullying
- B. Conducting peer mediation sessions
- C. Providing workshops on conflict resolution
- D. Promoting bystander intervention
Correct Answer: D
Rationale: Promoting bystander intervention is the most effective strategy as it empowers students to take action and prevent bullying incidents. By encouraging bystanders to intervene when they witness bullying, the behavior is less likely to continue. Zero-tolerance policies may have limited effectiveness as they often focus on punishment rather than prevention. Peer mediation and conflict resolution workshops are valuable but may not directly address the immediate need for bystander intervention in bullying situations.