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. “Increase your caloric intake by eating foods high in protein.”

This is the appropriate choice. Increasing caloric intake with high-protein foods can help meet nutritional needs for individuals with Crohn's Disease, especially if malabsorption is a concern.

B. “Include fresh fruits and vegetables at each meal.”

While fresh fruits and vegetables are generally healthy, they may exacerbate symptoms in some individuals with Crohn's Disease, especially during flare-ups. It may be advisable to choose cooked or processed fruits and vegetables to minimize irritation.

C. “Maintain your weight by eating high-fat foods.”

This statement is not advisable. High-fat foods can contribute to symptoms such as cramping and diarrhea in individuals with Crohn's Disease. A well-balanced diet with an appropriate mix of nutrients is generally recommended.

D. “Drink whole milk to ensure adequate calcium intake.”

This statement is not advisable without considering individual tolerance. Whole milk is high in fat and may be difficult to digest for some individuals with Crohn's Disease. Additionally, if lactose intolerance is present, it may worsen symptoms. Alternative sources of calcium may need to be considered.

A. Set the pad’s temperature to 42.2° C (108 F) B. Stop the treatment if the client’s skin becomes red. C. Leave the pad in place for at least 40 min. D. Use safety pins to keep the pad in place.

Correct Answer is B

Explanation

A. Set the pad’s temperature to 42.2° C (108 F).

The specific temperature setting for a heat application should be based on the healthcare provider's prescription and the therapeutic goals. The temperature should be within a safe and therapeutic range.

B. Stop the treatment if the client’s skin becomes red.

This is the correct choice. Redness on the skin during heat application may indicate potential skin irritation or the onset of a burn. Stopping the treatment if redness occurs is crucial to prevent further injury.

C. Leave the pad in place for at least 40 min.

The duration of heat application should also be based on the healthcare provider's prescription and therapeutic goals. Leaving the pad in place for a specific duration is important, but the exact time would depend on the therapeutic plan.

D. Use safety pins to keep the pad in place.

Safety pins should not be used to secure heat applications, as they can pose a risk of injury. Instead, healthcare professionals should use the appropriate securing devices provided with the heat application or follow facility protocols.

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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 with a client who has Crohn’s Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a parent of a child who has eczema. Which of the following instructions should the nurse include in the teaching?

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