a nurse is planning care for a client following the insertion of a chest tube and drainage system which of the following should not be included in the
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1. A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?

Correct answer: C

Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.

2. All of the following statements are true about donning sterile gloves except:

Correct answer: D

Rationale: When donning sterile gloves, it is essential to maintain sterility. The correct way to don sterile gloves includes grasping the outside of the cuff to put on the first glove and inserting the gloved fingers under the cuff outside the glove to put on the second glove. Adjustments should be made by sliding the fingers under the sterile cuff. It is crucial to remember that once the inside of the glove is touched during the donning process, it is no longer considered sterile.

3. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?

Correct answer: C

Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.

4. When caring for a client who speaks a language different from their own, what action should the nurse take?

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

5. Which deficiency is most commonly seen in individuals with alcohol use disorder?

Correct answer: A

Rationale: Thiamine deficiency, also known as Vitamin B1 deficiency, is the most common vitamin deficiency seen in individuals with alcohol use disorder. Chronic alcohol consumption can lead to decreased thiamine absorption and utilization, as well as poor dietary intake. Thiamine deficiency can result in serious neurological complications, such as Wernicke-Korsakoff syndrome, making it essential to address thiamine supplementation in individuals with alcohol use disorder.

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