Question

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?

Answer 1

Correct Answers:

Replace the unit when the drainage chamber is full.

Rationale :

🔷 A full chamber may result in fluid backflow into the pleural space, increasing the risk of tension pneumothorax.

🔷 The drainage system must be replaced once it reaches the full indicator to maintain negative pressure.

🔷 Allowing the system to overflow can compromise system function and safety.

🔷 Monitoring output helps detect excessive bleeding or complications.

🔷 Nurses must always verify the drainage volume and replace units before malfunction occurs.

🔷 This step is part of standard closed-chest drainage system protocols to protect lung re-expansion.

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Answer 2

Correct Answers:

"It is common for one breast to be larger than the other

Rationale :

🔸 Slight asymmetry between breasts is a normal anatomical variation and not a cause for concern.

🔸 This finding is especially common during hormonal fluctuations or developmental changes.

🔸 Asymmetry only becomes concerning if there's a sudden or recent change in size or shape.

🔸 Breast self-awareness includes knowing what's normal for the individual's body.

🔸 Teaching this normal variation can reduce unnecessary anxiety during self-examinations.

🔸 It also encourages clients to report only significant or new abnormalities, such as dimpling or lumps.

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Answer 3

Correct Answers:

Advise the client about increased dry mouth.

Rationale :

🔷 Dry mouth is a common side effect of clonidine due to reduced sympathetic outflow.

🔷 It results from the drug’s central alpha-2 adrenergic agonist action.

🔷 Clients should be informed to stay hydrated and use oral moisturizers or sugar-free gum.

🔷 Monitoring for this effect improves treatment adherence and comfort.

🔷 This teaching promotes early reporting and helps manage discomfort effectively.

🔷 Other common effects include drowsiness and hypotension, but dry mouth is most frequent.

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Answer 4

Correct Answers:

Platelets 60,000/mm3 (150,000 to 400,000/mm3)

Rationale :

🔸 A low platelet count increases the risk of bleeding during invasive procedures like liver biopsy.

🔸 Normal platelet range is 150,000–400,000/mm³; 60,000 is critically low.

🔸 Bleeding risk is elevated because platelets are essential for hemostasis and clot formation.

🔸 This abnormal value must be reported immediately before the procedure.

🔸 Proceeding without correction can lead to hemorrhagic complications.

🔸 The nurse’s role is to identify and communicate lab values that pose safety concerns.

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Answer 5

Correct Answers:

The client takes ibuprofen for headaches.

Rationale :

🔶 NSAIDs like ibuprofen can cause GI mucosal irritation, leading to small bleeding.

🔶 This bleeding may result in a false-positive fecal occult blood test.

🔶 The client should avoid NSAIDs before and during testing to ensure accuracy.

🔶 Nurses must review medication history when preparing clients for occult blood tests.

🔶 Other causes like hemorrhoids may affect results, but NSAIDs are a common culprit.

🔶 Proper instructions reduce diagnostic errors and unnecessary procedures

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Answer 6

Correct Answers:

Changed mental status

Rationale :

🔷 Older adults often present with atypical signs of infection, especially in UTIs.

🔷 Confusion, lethargy, or agitation may be the only early indicators of a bladder infection.

🔷 This change should be treated as an urgent finding requiring further evaluation.

🔷 Normal WBC and temperature may not rule out infection in the elderly.

🔷 Nurses must recognize these subtle cues to avoid delayed diagnosis.

🔷 Immediate reporting can prevent progression to sepsis or worsening status.

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Answer 7

Correct Answers:

"I can decrease my risk for a stroke by losing excess weight."

Rationale :

🔸 Excess weight contributes to hypertension, dyslipidemia, and insulin resistance.

🔸 Weight loss improves glycemic control and cardiovascular health.

🔸 Stroke risk is significantly reduced by addressing modifiable factors like obesity.

🔸 Diabetes already increases risk, so lifestyle modification is crucial.

🔸 Client education must include prevention strategies tied to current health conditions.

🔸 Encouraging realistic goals like weight reduction leads to better long-term outcomes.

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Answer 8

Correct Answers:

Perform suctioning.

Rationale :

🔶 Restlessness and crackles suggest retained respiratory secretions.

🔶 Suctioning helps clear the airway and improves oxygen exchange.

🔶 This is an immediate priority for tracheostomy care.

🔶 Crackles may worsen into respiratory distress if not addressed.

🔶 Routine suction is vital in clients with trach tubes to maintain patency.

🔶 Delay may lead to hypoxia or mucus plugging.

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Answer 9

Correct Answers:

"It is common for one breast to be larger than the other."

Rationale :

🔷 Natural breast asymmetry is normal and not a cause for alarm.

🔷 This helps clients focus on detecting new or sudden changes, not expected variation.

🔷 Reassurance reduces unnecessary worry during self-exams.

🔷 It promotes body awareness and confidence in self-assessment.

🔷 Knowing what's "normal" builds a reliable baseline.

🔷 It also emphasizes the importance of noticing deviation from baseline.

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Answer 10

Correct Answers:

"Use small, circular motions, working vertically up and down across the breast."

Rationale :

🔸 The vertical strip technique is the most effective BSE method.

🔸 Small, circular motions ensure that all breast tissue is thoroughly palpated.

🔸 This includes the axillary tail, where some breast cancers develop.

🔸 Using the pads of the fingers improves sensitivity to abnormalities.

🔸 Correct technique increases chances of early detection of masses or changes.

🔸 Teaching proper technique supports empowered self-care.

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QLexNursing

1 :
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?

2 :
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

4 :
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

5 :
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

6 :
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

7 :
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

9 :
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?

QLexNursing

1 : 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?

2 : A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

4 : A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

5 : A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

6 : A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

7 : A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

9 : A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

10 : A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?

1 :
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?

2 :
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

4 :
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

5 :
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

6 :
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

7 :
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

9 :
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?