A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

'It is unnecessary for you to go to the restroom at this time."

'I can assist you to the bathroom and back to bed."

'I cannot assist you at this time, please wait until I finish what I’m doing”.

'You cannot go to the bathroom.'

Answer and Explanation

The Correct Answer is B

Chest tubes are inserted to drain ﬂuid, blood, or air from the pleural space, which is the space between the lung and the chest wall. It is important to ensure that the chest tube is secured properly and the drainage system is functioning properly before the patient is ambulated. Additionally, the patient may experience discomfort or pain during ambulation, so it is important to assess and manage the patient's pain before and after ambulation.

Option A is not appropriate because it disregards the patient's need to use the restroom and may make the patient feel helpless or dependent.

Option c is not appropriate because it does not address the patient's request for assistance and may make the patient feel neglected or uncared for.

Option d is not appropriate because it is a directive statement that does not take into account the patient's autonomy or individual needs. It is important to involve the patient in the decision-making process and provide appropriate care based on their individual needs and preferences.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Three defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice B reason: This is correct because it shows that the PN is familiar with the nursing diagnosis criteria. One defining characteristic is the least number required for the diagnosis of Impaired Verbal Communication, according to the NANDA-I taxonomy.

Choice C reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Four defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice D reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Two defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

A. Put a hat in the toilet to collect proper output. B. Assess your patient’s lower extremities and lungs for ﬂuid retention. C. Educate her on the importance of writing down all ﬂuids she is drinking. D. Document the numbers anyway, there is a probable error with the intake number.

Correct Answer is B

Explanation

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

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A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The Practical Nurse (PN) assessing a client for the nursing diagnosis of Impaired Verbal Communication is aware that the least number of defining characteristics for this diagnosis is:

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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