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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cheese omelet
A cheese omelet may be acceptable for a Hindu diet, as it doesn't contain beef or pork. However, it's important to consider the individual's specific dietary preferences and any other restrictions they may follow.
B. Hamburger
A hamburger typically contains beef, which may not align with Hindu dietary laws. Hindus, in general, avoid beef, as the cow is considered a sacred animal in Hinduism.
C. Bologna sandwich
Similar to the hamburger, a bologna sandwich often contains pork products. Pork is generally avoided by individuals adhering strictly to Hindu dietary laws.
D. Steamed vegetables
Steamed vegetables are a safe option for a Hindu diet as they are plant-based and do not contain beef or pork. They align with the dietary preferences of many Hindus.
Correct Answer is D
Explanation
A. Noodles:
Noodles by themselves are typically a carbohydrate source and are lower in fat. However, it's essential to consider how they are prepared. If they are served with a high-fat sauce or other fatty ingredients, they may contribute to a higher fat intake.
B. Vegetable soup:
Vegetable soup, particularly if it is broth-based and contains a variety of vegetables, can be a healthy and lower-fat option. It provides vitamins, minerals, and fiber without a significant amount of fat.
C. Baked fish:
Baked fish is a lean source of protein and is generally lower in fat compared to fried or heavily processed options. The key is in the preparation method; baking is a healthier option than frying. However, it's essential to avoid high-fat toppings or sauces.
D. Cheddar cheese:
Cheddar cheese is a high-fat dairy product. Individuals with a history of pancreatitis are often advised to limit their fat intake, and high-fat foods like cheddar cheese can exacerbate symptoms. It's recommended to choose lower-fat or fat-free dairy alternatives.
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