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

Correct Answer: C

Rationale: Taping the connections on the client's chest tube prevents accidental disconnection, which could compromise the seal and lead to complications such as a pneumothorax. Looping the tubing (A) can obstruct drainage, stripping the tube (B) can damage lung tissue due to increased negative pressure, and placing the drainage system above the heart (D) prevents gravity drainage and risks fluid backflow into the pleural cavity.

Correct Answer: A

Rationale: Self-determination respects clients as autonomous individuals capable of informed decisions, exemplified by allowing a client to choose juice over water. Choices B, C, and D involve decisions that could endanger life or lack capacity, not reflecting appropriate self-determination.

Correct Answer: C

Rationale: Blood pressure and pulse indicate hemodynamic status, critical for an arterial laceration with life-threatening potential, making it the priority. Next of kin (A), medications (B), and respirations (D) are less urgent in this emergency.

Correct Answer: C

Rationale: Case management targets clients with complex, high-cost conditions like chronic heart failure and diabetes. Cystitis (A), hypertension (B), and a fracture (D) typically involve less complexity and cost.

Correct Answer: A

Rationale: The Rapid Response Team (RRT) intervenes for deteriorating clients to prevent arrest, making it the best action for a significant blood pressure drop. Documentation (B) is necessary but insufficient alone, notifying the provider (C) is secondary to RRT, and repeating in 15 minutes (D) delays critical care.