Question

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

Answer 1

Correct Answers:

Tape the connections on the client's chest tube.

Rationale :

🔹 Taping the chest tube connections ensures they remain secure and airtight, preventing air leaks and loss of negative pressure.

🔹 A leak can lead to tension pneumothorax, a life-threatening condition.

🔹 The drainage system should be placed below chest level, and tubing should remain straight to maintain proper drainage.

🔹 Stripping and looping the tubing are discouraged as they increase intrathoracic pressure and risk injury.

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Answer 2

Correct Answers:

Position the client supine.

Rationale :

🟠 Positioning the client supine allows easy access to the perineal area and prevents injury during catheter removal.

🟠 It provides stability and visibility for the nurse to deflate the balloon and remove the catheter smoothly.

🟠 The balloon should be fully deflated before removal to prevent trauma.

🟠 Using correct positioning helps reduce discomfort and maintains client dignity and safety.

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Answer 3

Correct Answers:

"We will notify the doctor if the pulse oximeter consistently reads 100%."

Rationale :

🟡 A consistent reading of 100% saturation is generally a normal and desired finding, not an emergency.

🟡 This response indicates a misunderstanding of pulse oximetry, warranting further teaching.

🟡 The probe can be rotated and placed on digits such as fingers or toes for accuracy and to prevent skin breakdown.

🟡 Movement can interfere with readings, and this should be minimized.

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Answer 4

Correct Answers:

Suprapubic discomfort

Rationale :

🟢 Suprapubic discomfort is a key indicator of bladder distention and need for catheterization in clients with paraplegia.

🟢 These clients may lack the ability to sense bladder fullness due to neurological deficits.

🟢 Scheduled intermittent catheterization helps prevent urinary retention and infection.

🟢 Prompt catheterization based on physical signs is part of neurogenic bladder care.

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Answer 5

Correct Answers:

When the client has the urge to defecate

Rationale :

🔵 Bowel training is most effective when timed with the client’s natural urge to defecate.

🔵 This approach reinforces the defecation reflex and promotes regularity.

🔵 Training should align with the client’s existing bowel patterns, not arbitrary schedules.

🔵 Recognizing body cues encourages autonomy and bowel control.

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Answer 6

Correct Answers:

Reflex incontinence

Rationale :

🟣 Reflex incontinence results from neurological impairment, such as spinal cord injury, where bladder empties involuntarily.

🟣 Clients do not feel the urge to void, and reflex emptying occurs without warning.

🟣 This type of incontinence is common in clients with neurogenic bladder.

🟣 Management includes scheduled catheterization to prevent urinary retention and infection.

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Answer 7

Correct Answers:

Ignoring the urge to defecate
Excessive laxative use
Inadequate fluid intake

Rationale :

Ignoring the urge to defecate

🟤 Suppressing the natural urge to defecate leads to water reabsorption from stool, making it harder and more difficult to pass.

🟤 Over time, this delays the defecation reflex, weakening the body’s ability to signal when it's time to go.

🟤 This behavior is a common contributor to chronic constipation, especially in institutionalized or busy individuals.

Excessive laxative use

🟤 Frequent use of laxatives can lead to dependence and reduce the colon’s natural ability to contract.

🟤 This disrupts the normal bowel motility, leading to slower stool transit when laxatives are stopped.

🟤 Chronic use can result in rebound constipation, requiring careful nursing education and tapering strategies.

Inadequate fluid intake

🟤 Low fluid intake causes the intestines to absorb more water from stool, resulting in dry, hard feces.

🟤 This can significantly slow down peristalsis and contribute to straining during bowel movements.

🟤 Ensuring adequate hydration is a fundamental step in preventing and managing constipation.

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Answer 8

Correct Answers:

Cracks in oral mucous membranes

Rationale :

🟣 Reflex incontinence results from neurological impairment, such as spinal cord injury, where bladder empties involuntarily.

🟣 Clients do not feel the urge to void, and reflex emptying occurs without warning.

🟣 This type of incontinence is common in clients with neurogenic bladder.

🟣 Management includes scheduled catheterization to prevent urinary retention and infection.

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Answer 9

Correct Answers:

Decrease in kidney function.

Rationale :

⚪ Aging reduces renal function, impairing the kidneys’ ability to conserve water and concentrate urine.

⚪ This increases the risk of dehydration, especially in older adults who already drink less.

⚪ Decreased renal function leads to fluid loss and electrolyte imbalances.

⚪ Nurses should monitor intake and output closely in the elderly.

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Answer 10

Correct Answers:

Don sterile gloves before inserting the indwelling urinary catheter.

Rationale :

🔷 The insertion of an indwelling catheter is a sterile procedure, and sterile gloves are essential to maintain aseptic technique.

🔷 This helps prevent the introduction of pathogens into the urinary tract, reducing the risk of catheter-associated urinary tract infections (CAUTIs).

🔷 Non-sterile gloves are not appropriate during catheter insertion but may be used for catheter care afterward.

🔷 Sterile technique ensures both patient safety and compliance with infection control standards.

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QLexNursing

1 :
A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

2 :
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

3 :
A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

4 :
A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

5 :
A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

6 :
A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

7 :
A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

8 :
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

9 :
A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

10 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?

QLexNursing

1 : A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

2 : A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

3 : A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

4 : A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

5 : A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

6 : A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

7 : A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

8 : A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

9 : A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

10 : A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?

1 :
A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

2 :
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

3 :
A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

4 :
A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

5 :
A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

6 :
A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

7 :
A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

8 :
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

9 :
A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

10 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?