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 B

Explanation

A. "I will rest for at least 30 minutes before eating."
This statement is appropriate. Resting before meals can help conserve energy and reduce dyspnea (shortness of breath) during eating for individuals with COPD.

B. "I will drink plenty of beverages with my meals."
This statement indicates a need for further teaching. Excessive fluid intake during meals can contribute to feelings of fullness and increase the risk of bloating, making it more difficult for the client with COPD to breathe comfortably.

C. "I will eat five or six small meals each day."
This statement is appropriate. Eating smaller, more frequent meals can help prevent overdistension of the stomach and reduce the feeling of fullness, making it easier for the client to breathe.

D. "I will increase my intake of protein."
This statement is appropriate. Adequate protein intake is important for individuals with COPD to support respiratory muscle function and overall nutritional status.

A. Limit potassium rich foods in the diet. B. Decrease sodium intake. C. Increase calorie intake. D. Consume more calories from carbohydrates than protein.

Correct Answer is B

Explanation

A. Limit potassium-rich foods in the diet.

Limiting potassium is not a typical dietary modification for Cushing's disease. Potassium levels are usually affected in conditions such as Addison's disease, where there is a deficiency of cortisol. In Cushing's disease, the focus is more on sodium balance.

B. Decrease sodium intake.

This is the correct choice. Decreasing sodium intake is a dietary modification relevant to individuals with Cushing's disease. Excessive cortisol production can lead to sodium and water retention, and reducing sodium intake helps manage fluid balance.

C. Increase calorie intake.

While weight gain is a common symptom in individuals with Cushing's disease, simply increasing calorie intake may not be the most specific or appropriate dietary modification. Attention to overall dietary balance and specific components like sodium is more relevant.

D. Consume more calories from carbohydrates than protein.

The macronutrient composition of the diet (carbohydrates vs. protein) is not a specific consideration for individuals with Cushing's disease. The focus is more on overall dietary balance and addressing sodium intake.

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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 reinforcing teaching for a client who has COPD. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

A nursing is reviewing nutrition therapy with a client who has Cushing’s disease. Which of the following dietary modifications should the nurse include in this discussion?

Correct Answer is B

Explanation

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