a nurse is caring for a client post surgery with a chest tube what is the most important assessment
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Nursing Elites

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1. A client post-surgery has a chest tube. What is the most important assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the chest tube is functioning properly. This is crucial post-surgery to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube, positioning the client, or encouraging coughing are not appropriate assessments for a client with a chest tube post-surgery and could lead to serious issues if done incorrectly.

2. A healthcare provider is collecting data from a client who has multiple sclerosis. Which of the following findings should the healthcare provider expect?

Correct answer: B

Rationale: Ataxia, which refers to difficulty with coordination, is a common symptom seen in individuals with multiple sclerosis. Nystagmus, the involuntary eye movement, can also occur in multiple sclerosis but is not as common as ataxia. Fatigue is a common symptom in multiple sclerosis, but ataxia is more specific. Fever is not a typical finding associated with multiple sclerosis.

3. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?

Correct answer: A

Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.

4. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?

Correct answer: B

Rationale: Corrected Rationale: Low prealbumin levels are indicative of malnutrition, which is common in individuals with anorexia nervosa. Iron levels, serum creatinine, and calcium levels are not typically affected in the same way by anorexia nervosa, making choices A, C, and D incorrect.

5. What should a healthcare professional do when a client with anorexia nervosa insists on working out constantly?

Correct answer: D

Rationale: When dealing with a client with anorexia nervosa who insists on working out constantly, it is crucial to address the situation sensitively. Speaking to the client privately to uncover the source of the obsession is the most appropriate action. This approach allows the healthcare professional to understand the underlying reasons for the behavior and work towards a solution together. Choices A and B could potentially exacerbate the client's condition by either enabling the behavior or imposing restrictions without addressing the root cause. While choice C is important, simply discussing the risks may not address the client's compulsion to exercise excessively.

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