A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Avoid discussing the client's fears.

Offer the client several choices at mealtimes.

Remind the client of the day and time often.

Alternate daily caregivers.

Answer and Explanation

The Correct Answer is C

Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.

Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.

Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.

Alternating daily caregivers can disrupt continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.

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Correct Answer is A

Explanation

Ensuring the device is kept below the level of the client's chest is important to ensure that the drainage system functions properly by allowing the fluid and air to flow downhill. Placing the device below the level of the chest helps facilitate gravity drainage.

Continuous suction is required for proper functioning of the chest tube drainage system. Clamping the chest tube can disrupt the suction and impede the removal of air or fluid from the pleural space. Only in specific circumstances, such as when changing the drainage system or assessing for air leaks, may the healthcare provider request a temporary clamping of the chest tube.

Positioning the client semi-Fowler's, with the head of the bed elevated, can help promote lung expansion and improve oxygenation. The specific positioning may vary depending on the client's condition and the healthcare provider's recommendations.

The nurse should empty the collection chamber as per the facility's protocol, which typically includes monitoring the drainage and emptying it when it reaches a certain level. Regular emptying of the collection chamber helps maintain proper functioning of the chest tube system and allows for accurate measurement of drainage output.

A. 32 lb B. B.8 lb C. 16 lb D. 24 lb

Correct Answer is C

Explanation

For a client with a prepregnancy BMI of 30.5, the acceptable weight gain during pregnancy would be around 11 to 20 pounds (5 to 9 kilograms) according to the guidelines set by the Institute of Medicine (IOM).

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A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should include that which of the following is an acceptable weight gain for this client?

Correct Answer is C

Explanation

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