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Which intervention is most important when caring for a client with a chest tube?
- A. Keep the drainage system at chest level.
- B. Ensure that the chest tube is clamped at all times.
- C. Strip the chest tube every shift.
- D. Ensure that the chest tube is connected to a water-seal drainage system.
Correct Answer: D
Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.
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A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
- A. Increase fluid intake to 3 liters per day.
- B. Limit sodium intake to 2 grams per day.
- C. Avoid foods high in potassium.
- D. Increase protein intake to promote healing.
Correct Answer: B
Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Increasing fluid intake (A), avoiding potassium (C), and increasing protein intake (D) are not appropriate dietary instructions for heart failure management.
A staff member is assigned to care for a close friend in the hospital setting. Which action should the staff member take first when given the assignment?
- A. Notify the friend that all medical information will be kept confidential.
- B. Explain the relationship to the charge nurse and ask for reassignment.
- C. Approach the client and ask if the assignment is uncomfortable.
- D. Accept the assignment but protect the client's confidentiality.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?
- A. Determine the client's sleep and activity pattern
- B. Obtain a prescription for the client to take when stressed
- C. Refer the client for a sleep study and neurological follow-up
- D. Teach coping strategies to use when feeling stressed
Correct Answer: D
Rationale: Teaching coping strategies is an appropriate first intervention for a client experiencing sleep difficulties and stress. It can help manage stress and improve sleep without immediately resorting to medication. By teaching coping strategies, the nurse empowers the client to address the underlying issues contributing to his sleep problems rather than just providing a temporary solution. Referring for a sleep study and neurological follow-up may be considered later if the client's sleep issues persist despite implementing coping strategies.
The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?
- A. Administration of plasma expanders
- B. Use of careful handwashing technique
- C. Application of a topical antibacterial cream
- D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections.
A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?
- A. Ask the wife how she would like to participate in the client's care.
- B. Provide the wife with information about hospice.
- C. Encourage the wife to visit during and after painful treatments are completed.
- D. Refer the wife to a support group for family members of those dying of cancer.
Correct Answer: A
Rationale: During this difficult time of coping with terminal cancer diagnosis, involving the wife in the care process can help her feel more in control and connected. This can be beneficial for both the client and his wife, as it fosters a collaborative approach to care and ensures the wife's needs and preferences are considered.