A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse

take?

Keep the collection device below the level of the client's chest.

Lay the client flat to avoid leaks in the tubing.

Clamp the tube when the client is ambulating...

Coil the tubes carefully to prevent kinking.

Answer and Explanation

The Correct Answer is A

A. Keeping the collection device below the level of the client’s chest prevents backflow of drainage into the pleural space.
B. The client should be positioned to promote lung expansion, often sitting up, not necessarily flat.
C. Clamping the chest tube is generally avoided as it can cause tension pneumothorax or other complications.
D. Tubing should be kept straight without coiling to prevent kinking and obstruction.

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Correct Answer is D

Explanation

A. Controlling impulsive behavior is more commonly associated with right hemispheric strokes due to impaired judgment and spatial awareness.
B. Improving left-side motor function would be a goal for a right hemispheric CVA because motor deficits occur on the side opposite the brain injury.
C. Loss of depth perception is typically a problem with right hemispheric damage affecting spatial-perceptual skills.
D. Left hemispheric strokes often affect language centers, leading to aphasia. Therefore, a primary rehabilitation goal is improving communication abilities.

A. Epinephrine administration B. Intubation C. Amiodarone administration D. Defibrillation

Correct Answer is D

Explanation

A. Epinephrine is important but given after defibrillation attempts during cardiac arrest.
B. Intubation is necessary for airway management but follows immediate defibrillation.
C. Amiodarone is used for refractory ventricular fibrillation after defibrillation attempts.
D. Defibrillation is the priority and most effective immediate treatment for ventricular fibrillation to restore a perfusing rhythm.

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A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Correct Answer is D

Explanation

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions will the nurse prioritize first?

Correct Answer is D

Explanation

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