Exhibits

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)

Start the prescribed antibiotic

Discontinue nasogastric tube

Reinforce preoperative teaching

Provide the client with ice chips

Answer and Explanation

The Correct Answer is C

A. Start the prescribed antibiotic: There is no indication of infection in the current clinical findings; antibiotics are typically used to treat bacterial infections, which are not yet evident.
B. Discontinue nasogastric tube: The nasogastric tube should remain in place as it helps relieve the symptoms of small bowel obstruction (e.g., vomiting and bloating).
C. Reinforce preoperative teaching: The client is on NPO status, which may suggest preparation for a surgical intervention to address the obstruction. Reinforcing preoperative teaching would be beneficial to ensure the client understands the procedure.
D. Provide the client with ice chips: The client is on NPO status, and consuming food or fluids is contraindicated due to the potential for aspiration or worsening of the condition (e.g., bowel obstruction or pancreatitis).

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Correct Answer is D

Explanation

A. Clamp the tube for 30 min every 8 hr: Clamping a chest tube increases the risk of tension pneumothorax and is contraindicated unless ordered by a provider.
B. Pin the tubing to the client's bed sheets: Pinning can cause disconnection or kinking of the tubing, leading to drainage issues.
C. Monitor for at least 150 mL of drainage every hour: Drainage greater than 100 mL/hour, especially after the first hour, should be reported as it may indicate hemorrhage.
D. Replace the unit when the drainage chamber is full. A full drainage chamber must be replaced to ensure the system functions properly and prevents complications like backflow.

A. Restrict visitors to family members until the client is able to wear a prosthesis. B. Encourage the client to talk with another client who completed rehabilitation for amputation. C. Instruct the client to ignore phantom pain sensations. D. Suggest that family members bring clothing for the client from home. E. Ask the client to describe her feelings about the loss of the affected limb.

Correct Answer is ["B","D","E"]

Explanation

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors may increase isolation and hinder emotional support.
B. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support can provide emotional reassurance and motivate the client in their recovery process.
C. Instruct the client to ignore phantom pain sensations: Phantom pain is real and should not be dismissed; it requires management through medication or other interventions.
D. Suggest that family members bring clothing for the client from home: Familiar clothing can improve self-esteem and promote adjustment to body image changes.
E. Ask the client to describe her feelings about the loss of the affected limb: Exploring the client’s feelings helps address emotional and psychological aspects of coping with amputation.

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Exhibits Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Exhibits

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client.)