The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?

Correct Answer: C

Rationale: In caring for a client with a chest tube post-surgery, it is crucial for the chest drainage system to remain below chest level to ensure proper drainage of fluids by gravity. Option C is the correct answer because if the drainage system is positioned above the chest, it can lead to backflow of fluids into the chest cavity, potentially causing complications like pneumothorax or hemothorax. Option A is incorrect because securely taping the chest tube at the insertion site is a proper procedure to prevent dislodgement. Option B is incorrect as having the water seal chamber filled to the correct level ensures proper functioning of the system. Option D is incorrect as the absence of air leaks is important to maintain the system's integrity. Educationally, understanding the correct positioning of a chest drainage system is vital for nurses caring for post-operative patients with chest tubes to prevent complications and ensure optimal recovery. Nurses must possess the knowledge and skills to assess, maintain, and troubleshoot chest drainage systems effectively to provide safe and effective care to their patients.

Correct Answer: C

Rationale: In this scenario, the correct response (option C) demonstrates empathy and a focus on problem-solving. By acknowledging the UAP's feelings and suggesting a collaborative approach to address the challenging situation, the nurse validates the UAP's emotions and fosters a supportive environment. This response promotes open communication, teamwork, and a patient-centered approach to care. Option A is incorrect because it dismisses the UAP's feelings and places the blame on the client, lacking empathy and problem-solving. Option B is not ideal as it puts the responsibility solely on the nurse to resolve the issue, missing the opportunity to involve the UAP in finding a solution collaboratively. Option D is inappropriate as it ignores the UAP's emotional distress and suggests avoiding the problem, which does not address the underlying issue or support the UAP effectively. Educationally, this scenario highlights the importance of effective communication, teamwork, and empathy in healthcare settings. It emphasizes the need for nurses to support and empower their colleagues, fostering a positive work environment and enhancing patient care outcomes through collaborative problem-solving.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Obtain more details of the client's claim of abuse. This is the most appropriate initial action because it prioritizes the client's safety and well-being. By gathering more information about the alleged abuse, the nurse can assess the situation comprehensively before taking further steps. Option A, focusing on reality orientation, is not the most immediate concern when a client discloses abuse. While it is important in certain situations, addressing the abuse claim takes precedence. Option B, assisting with the report to the police, should come after verifying the client's claim to ensure accuracy and appropriateness of involving law enforcement. Option D, documenting the statement on the client's chart, is important but should follow a thorough assessment and investigation of the abuse allegation to ensure proper documentation. Educationally, this question highlights the critical thinking skills needed in nursing practice when faced with sensitive and potentially harmful situations. It emphasizes the importance of assessing and investigating before taking action to ensure the best possible outcome for the client.

Correct Answer: B

Rationale: The correct answer is B) Moderate impairment. The Glasgow Coma Scale (GCS) is a neurological scale that assesses a patient's level of consciousness following a brain injury. A GCS score of 10 indicates a moderate impairment in the client's level of consciousness. Option A) Mild impairment is incorrect because a GCS score of 13-15 is considered mild impairment, not 10. Option C) Severe impairment is also incorrect as GCS scores indicating severe impairment typically fall below 8. Option D) Normal is incorrect because a GCS score of 10 does not indicate a normal level of consciousness. In an educational context, understanding the GCS scoring system is crucial for healthcare professionals, especially in emergency situations like motor vehicle accidents. It helps in quickly assessing and communicating a patient's neurological status, guiding treatment decisions and predicting outcomes. Healthcare providers must accurately interpret GCS scores to provide appropriate care and interventions based on the level of impairment indicated.

Correct Answer: C

Rationale: In the context of nursing delegation principles, the correct answer is option C, assisting the client with ambulation, as it falls within the scope of practice for unlicensed assistive personnel (UAP). UAPs are trained to provide direct client care tasks that do not require nursing judgment or assessment. They can safely assist clients with activities of daily living, such as ambulation, under the supervision of a registered nurse. Option A, assessing the client's ability to ambulate safely, involves a nursing assessment and requires critical thinking skills to determine the client's readiness for ambulation. This task should be performed by a registered nurse. Option B, documenting the client's tolerance of ambulation, involves recording and interpreting client data, which requires nursing judgment and accountability. This task is the responsibility of the nurse to ensure accurate documentation of the client's condition. Option D, evaluating the client's pain level after ambulation, involves assessing the client's response to ambulation and making decisions based on this assessment. This task requires nursing assessment and intervention to address any pain issues effectively. Educationally, understanding the principles of delegation is crucial for nurses to provide safe and efficient care. By knowing which tasks can be delegated to UAPs and which require nursing expertise, nurses can prioritize their responsibilities and ensure that each team member is working within their scope of practice to promote optimal patient outcomes.