A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider? Select all that apply.
Mental confusion
Temperature
Heart rate
Urine output
Pain
Serum amylase level
Respiratory status
Sodium level
Cold, clammy skin
Blood pressure
Correct Answer : B,E
b. Ensure the chest tube remains below the level of the client's chest.
e. Reinforce loose dressing around the tube.
When managing a chest tube, it is important for the nurse to ensure that the chest tube remains below the level of the client's chest¹. This helps to prevent air from entering the pleural space and allows for proper drainage of fluid. The nurse should also reinforce any loose dressing around the tube to maintain a secure seal¹.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A 24-hour creatinine clearance test is used to evaluate how well the kidneys are functioning by measuring the amount of creatinine in the blood and urine over a 24-hour period. During the test, the client is asked to discard their first-morning void and then collect all urine for the next 24 hours.
Option A is incorrect because a protein-rich diet can affect the creatinine levels in the urine, which can result in inaccurate test results. Therefore, the nurse should advise the client to avoid a protein-rich diet during the collection period.
Option B is incorrect because blood glucose levels are not relevant to a 24-hour creatinine clearance test. Therefore, the nurse should not ask the client to record their blood glucose level each time they void.
Option D is incorrect because using an antiseptic towel to cleanse the perineal area can also affect the test results by introducing contaminants into the urine sample. Therefore, the nurse should advise the client to cleanse the perineal area with soap and water or an alcohol wipe.

Correct Answer is B
Explanation
Giving the client the opportunity to participate in decision-making regarding the timing of treatments and procedures respects their autonomy and allows them to have some control over their care.
Be honest with the client about the prognosis: By providing accurate and honest information, the nurse respects the client's right to know and be involved in decision-making regarding their healthcare.
Provide privacy during client care procedures: Respecting the client's privacy during care procedures allows them to maintain a sense of dignity and control over their body.
Administer pain medication on a routine schedule: Ensuring that pain medication is provided on a routine schedule allows the client to have control over their pain management and helps maintain their comfort and quality of life
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