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 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.
Correct Answer is C
Explanation
A. Liver
Liver is high in cholesterol and should be limited in a low-cholesterol diet. It is a rich source of dietary cholesterol.
B. Milk
While milk itself is not particularly high in cholesterol, it contains saturated fat. In a low-cholesterol diet, it is often recommended to choose low-fat or fat-free dairy products to reduce saturated fat intake.
C. Beans
This is the correct choice. Beans are a plant-based protein source that is low in cholesterol. They are high in fiber and contribute to heart-healthy eating.
D. Eggs
Eggs are a source of dietary cholesterol. While current dietary guidelines suggest that moderate egg consumption may be acceptable for many individuals, those following a low-cholesterol diet may need to be mindful of their overall cholesterol intake from various sources.
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