Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice 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?
A. Monitor for at least 150 mL of drainage every hour.
Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as a pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.
B. Clamp the tube for 30 min every 8 hr.
Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.
C. Pin the tubing to the client's bed sheets.
Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.
D. Replace the unit when the drainage chamber is full.
The chest tube unit should only be replaced when there is a problem with the unit or the seals.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.
Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.
Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.
Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.
Similar Questions
A nurse is caring for a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report?
A. Temperature 37.2° C (99° F)
A temperature of 37.2°C (99°F) is within the normal range and does not require reporting.
B. Serosanguineous drainage at the incision site
Serosanguineous drainage at the incision site is normal within the first few days postoperatively.
C. Red streaks along the incision
Red streaks along the incision. This is a possible sign of infection and should be reported to the healthcare provider. A temperature of 37.2°C (99°F) is within the normal range and does not require reporting. Serosanguineous drainage at the incision site is normal within the first few days postoperatively. Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.
D. Hypoactive bowel sounds in all four quadrants
Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.
Full Explanation
Red streaks along the incision. This is a possible sign of infection and should be reported to the healthcare provider. A temperature of 37.2°C (99°F) is within the normal range and does not require reporting. Serosanguineous drainage at the incision site is normal within the first few days postoperatively. Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.
Choice A: A temperature of 37.2°C (99°F) is within the normal range and does not require reporting.
Choice B: Serosanguineous drainage at the incision site is normal within the first few days postoperatively.
Choice D: Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.
A nurse is reinforcing teaching with a client who is recovering from gastroenteritis and is beginning oral intake. Which of the following foods should the nurse recommend?
A. Orange juice
Orange juice is acidic and can irritate the stomach lining, which is not ideal for someone recovering from gastroenteritis. Acidic foods and drinks can exacerbate symptoms like nausea and stomach pain.
B. Cream of broccoli soup
Cream of broccoli soup is not recommended because it is a dairy-based product. Dairy can be difficult to digest and may worsen symptoms like diarrhea and stomach cramps during the recovery phase of gastroenteritis.
C. Lime ice popsicle
Lime ice popsicle is a good choice because it is a clear liquid that can help with hydration and is easy on the stomach. Ice popsicles can also help soothe the throat and provide a small amount of sugar for energy without overwhelming the digestive system.
D. Vanilla pudding
Vanilla pudding, although soft, contains dairy, which can be hard to digest for someone recovering from gastroenteritis. Dairy products can lead to further gastrointestinal discomfort.
Full Explanation
The correct answer is choice C. Lime ice popsicle.
Choice A rationale:
Orange juice is acidic and can irritate the stomach lining, which is not ideal for someone recovering from gastroenteritis. Acidic foods and drinks can exacerbate symptoms like nausea and stomach pain.
Choice B rationale:
Cream of broccoli soup is not recommended because it is a dairy-based product. Dairy can be difficult to digest and may worsen symptoms like diarrhea and stomach cramps during the recovery phase of gastroenteritis.
Choice C rationale:
Lime ice popsicle is a good choice because it is a clear liquid that can help with hydration and is easy on the stomach. Ice popsicles can also help soothe the throat and provide a small amount of sugar for energy without overwhelming the digestive system.
Choice D rationale:
Vanilla pudding, although soft, contains dairy, which can be hard to digest for someone recovering from gastroenteritis. Dairy products can lead to further gastrointestinal discomfort.
A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?
A. Social worker
A social worker can help the client and their family with emotional and social issues related to the condition.
B. Herbalist
An herbalist is not necessary for the management of disuse syndrome.
C. Dietitian
A dietitian can help the client with their nutritional needs but may not address their physical functioning.
D. Occupational therapist
Disuse syndrome is a condition that occurs when a person experiences a reduction in physical activity, resulting in a decline in physical function. An occupational therapist can help the client improve their ability to perform daily activities and improve their overall functioning.
Full Explanation
Occupational therapist. Disuse syndrome is a condition that occurs when a person experiences a reduction in physical activity, resulting in a decline in physical function. An occupational therapist can help the client improve their ability to perform daily activities and improve their overall functioning. A social worker can help the client and their family with emotional and social issues related to the condition. An herbalist is not necessary for the management of disuse syndrome. A dietitian can help the client with their nutritional needs but may not address their physical functioning.