A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client’s bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?

To help the nurse validate the client’s reports of pain

To increase positive pressure in the chest

To assist the client with ADLS

To modify the client’s perception of pain

Answer and Explanation

The Correct Answer is C

A. To help the nurse validate the client’s reports of pain

This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.

B. To increase positive pressure in the chest

This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.

C. To assist the client with ADLs (Activities of Daily Living)

This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.

D. To modify the client’s perception of pain

This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.

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Correct Answer is A

Explanation

A. Close the curtains around the client’s bed.

Closing the curtains around the client's bed is a practical way to maintain the client's privacy during a bed bath. This action provides a visual barrier, ensuring that the client is shielded from the view of others in the room.

B. Close the door of the client’s room.

Closing the door is another way to enhance privacy, but it may not be as feasible in all situations. Closing the curtains provides immediate visual privacy without necessarily closing off the entire room.

C. Ask family members to leave the room.

This option is appropriate if family members are present and their presence is not essential for the bed bath. Asking them to step out temporarily can enhance the client's privacy.

D. Use a blanket to cover the client.

While using a blanket is a way to cover and provide modesty during the bed bath, closing the curtains is a more direct measure to maintain visual privacy. Blankets can be used as needed during the bed bath process.

A. “I will keep my baby’s head slightly elevated during the feeding.” B. “I will hold my baby close to me while feeding.” C. “Each feeding should last about 15 minutes.” D. “Propping a bottle can cause otitis media.”

Correct Answer is C

Explanation

A. “I will keep my baby’s head slightly elevated during the feeding.”

This statement is correct. Keeping the baby's head slightly elevated during feeding can help prevent ear infections (otitis media) and is a recommended practice.

B. “I will hold my baby close to me while feeding.”

Holding the baby close during feeding promotes bonding and is generally considered a good practice for both bottle-feeding and breastfeeding.

C. “Each feeding should last about 15 minutes.”

This statement indicates a need for further teaching. The duration of a feeding can vary among infants, and it's not advisable to put a strict time limit on each feeding. It's important to follow the baby's cues and allow for individual variations in feeding patterns.

D. “Propping a bottle can cause otitis media.”

This statement is correct. Propping a bottle can lead to ear infections (otitis media) and is not a safe or recommended practice. The baby should be held during feedings to prevent these issues.

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A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client’s bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client’s privacy?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about bottle-feeding with a client who is postpartum. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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