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What action should the healthcare provider take for a patient with a chest tube?
- A. Strip the drainage tubing every 4 hours.
- B. Keep the drainage system below the level of the patient's chest.
- C. Clamp the chest tube when ambulating the patient.
- D. Ensure the water seal chamber is filled to the prescribed level.
Correct Answer: D
Rationale: Ensuring the water seal chamber is filled to the prescribed level is essential for the chest tube's effective functioning. This maintains the integrity of the system, prevents air from entering the pleural space, and facilitates proper drainage. Stripping the drainage tubing, keeping the drainage system below the chest level, or clamping the chest tube during ambulation are not recommended practices and can lead to complications.
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A client has a new prescription for digoxin, and a nurse is providing teaching. Which of the following client statements indicates an understanding of the teaching?
- A. I will take my pulse before taking this medication.
- B. I will take this medication with an antacid.
- C. I will double the dose if I miss one.
- D. I will avoid eating bananas.
Correct Answer: A
Rationale: The correct answer is A because taking the pulse before administering digoxin is crucial as the medication can cause bradycardia. Monitoring the pulse helps in identifying any signs of bradycardia, a common side effect of digoxin. Options B, C, and D are incorrect. Taking digoxin with an antacid may interfere with its absorption. Doubling the dose if a dose is missed can lead to overdose and adverse effects. Avoiding bananas is not specifically related to digoxin therapy.
What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?
- A. Flush the feeding tube with water before and after feedings.
- B. Elevate the head of the bed to 30-45 degrees during feedings.
- C. Administer the feeding slowly.
- D. Check the client's weight daily.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.
A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?
- A. Massage the reddened area.
- B. Apply a heating pad to the area.
- C. Elevate the head of the bed to 45 degrees.
- D. Reposition the client every 2 hours.
Correct Answer: D
Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.
A healthcare professional is assessing a client who has fluid volume overload. Which of the following findings should the healthcare professional expect?
- A. Hypotension.
- B. Bradycardia.
- C. Crackles in the lungs.
- D. Flat neck veins.
Correct Answer: C
Rationale: Crackles in the lungs are a classic sign of fluid volume overload. When there is an excess of fluid in the lungs, it can manifest as crackling sounds upon auscultation. This finding indicates the accumulation of fluid in the alveoli and interstitial spaces of the lungs, which is a common manifestation of fluid volume overload.
What action should a healthcare provider take for a client with a new colostomy?
- A. Empty the colostomy bag when it is half full.
- B. Place aspirin in the colostomy bag to decrease odor.
- C. Use sterile technique when caring for the stoma.
- D. Change the pouch every 8 hours.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.