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 C

Explanation

A. Keep the prosthesis in direct contact with the residual limb.

This statement is incorrect. Prosthetic care typically involves using a liner or sock between the residual limb and the prosthesis. This helps to provide cushioning, absorb sweat, and reduce friction, contributing to comfort and preventing skin irritation.

B. Apply a moisturizing lotion or oil to the stump daily.

Moisturizing the skin on the residual limb is generally advisable to prevent dryness and irritation. However, it's crucial to ensure that the skin is completely dry before attaching the prosthesis. Moisturizing can help maintain skin health and comfort.

C. Dry the prosthesis socket completely before applying it to the limb.

This statement is correct. Ensuring that the prosthesis socket is thoroughly dry before application is crucial to prevent skin irritation and ensure a secure fit. Moisture between the skin and the prosthesis can contribute to discomfort and skin-related issues.

D. Expect some skin irritation from the prosthesis.

While it is common to experience minor skin irritation initially as the individual adjusts to the prosthesis, persistent or severe irritation should be addressed. The goal is to achieve a proper fit and minimize skin-related problems through appropriate care and adjustments.

A. The stockings are used to reduce pain. B. The stockings prevent varicose veins. C. The stockings prevent venous stasis. D. The stockings replace the need for postoperative leg exercises.

Correct Answer is C

Explanation

A. The stockings are used to reduce pain.

This statement is not accurate. While antiembolism stockings may provide some relief from discomfort and swelling, their primary purpose is to prevent venous stasis and reduce the risk of blood clots, not to directly reduce pain.

B. The stockings prevent varicose veins.

This statement is not entirely accurate. While compression stockings can provide some support to veins, their primary role is in preventing blood clots (venous thromboembolism) rather than preventing varicose veins, which are typically related to venous insufficiency.

C. The stockings prevent venous stasis.

This is the correct answer. Antiembolism stockings are specifically designed to prevent venous stasis, which refers to the slowing or stagnation of blood flow in the veins. They exert gentle pressure on the legs to enhance blood circulation and reduce the risk of blood clots.

D. The stockings replace the need for postoperative leg exercises.

This statement is not accurate. While antiembolism stockings are a preventive measure, they do not replace the need for postoperative leg exercises. Leg exercises are important for promoting circulation, preventing complications such as deep vein thrombosis (DVT), and maintaining overall mobility after surgery.

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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 about prosthesis care for a client following a below-the-knee amputation. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

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