A nurse is assisting in the care of a client.

Admission Assessment.

1500: Client transferred from postanesthesia care unit, following a left lung lobectomy.

Client alert and oriented to person, place, time,. and situation.

Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest.

Water seal chest tube drainage system has 100 mL sanguineous drainage.

Right lung sounds clear.

Left lung sounds diminished.

For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.

Clamp chest tube when client ambulates.

Report burning pain in chest to provider.

Reinforce dressing around the tube as needed if it loosens.

Strip the tubing twice daily to ensure patency.

Maintain chest tube below the chest.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated.

Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort.

Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.

Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.

Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

The statement, "You will no longer be infectious once you have completed a course of antibiotics," is incorrect. Genital herpes is a viral infection caused by the herpes simplex virus (HSV) Antibiotics do not treat viral infections, including herpes. Antiviral medications are used for herpes management, but they do not cure the infection. The virus can remain dormant in the body and reactivate.

Choice B rationale:

"You should increase fluid intake to relieve dysuria" is a correct and important piece of advice. Dysuria (painful urination) can be a symptom of genital herpes. Increasing fluid intake helps dilute urine, reducing discomfort during urination.

Choice C rationale:

"You should have the lesions drained as they appear" is incorrect. Lesion drainage is not a standard treatment for genital herpes. Antiviral medications are typically prescribed to manage outbreaks and reduce their duration and severity.

Choice D rationale:

"You should wear nylon underwear until the lesions have healed" is not the recommended guidance. Wearing loose-fitting cotton underwear is generally advised for comfort and to minimize irritation during a herpes outbreak. Nylon underwear may cause friction and discomfort.

A. Nausea. B. Hand tremors. C. Swelling of the lips. D. Hyperglycemia.

Correct Answer is C

Explanation

Choice A rationale:

Epinephrine is not typically used to treat nausea. Nausea is usually managed with antiemetic medications.

Choice B rationale:

Epinephrine is not used to treat hand tremors. Hand tremors may be related to various conditions, and their management would depend on the underlying cause.

Choice C rationale:

The correct manifestation that epinephrine can help treat is "Swelling of the lips." Epinephrine is commonly used to treat severe allergic reactions (anaphylaxis), which can cause swelling of the lips, tongue, and throat. Epinephrine helps to reverse these symptoms by constricting blood vessels and opening the airways.

Choice D rationale:

Epinephrine is not used to treat hyperglycemia. Hyperglycemia is managed with insulin or other antidiabetic medications, not epinephrine.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has genital herpes.Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN.The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

Correct Answer is C

Explanation

A nurse is assisting a client who has cancer to select high-protein foods. Which of the following foods should the nurse recommend as the highest source of protein?

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine.Which of the following instructions should the nurse include in the teaching?

A nurse is preparing to administer carbamazepine suspension 150 mg via NG tube every 6 hr. The amount available is 100 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?

A nurse is reinforcing teaching with a client who has hypothyroidism and a new prescription for levothyroxine.The nurse should instruct the client to notify the provider of which of the following manifestations of thyrotoxicosis?

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.Which of the following actions should the nurse take?