NCLEX for RN - Leadership and Management (11-15)

11. A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. The nurse intervenes if the student writes which incorrect intervention in the plan?

a) position the client in semi-fowler's position
b) add water to the suction chamber as it evaporates
c) tape the connection sites between the chest tube and the drainage system
d) instruct the client to avoid coughing and deep breathing

12. A nurse is caring for a client who has just had a plaster leg cast applied. The nurse would plan to prevent the development of compartment syndrome is instructing the licensed practical nurse assigned to care for the client to:

a) elevate the limb and apply ice to the affected leg
b) elevate the limb and cover the limb with bath blankets
c) place the leg in a slightly dependent  position and apply ice to the affected leg
d) keep the leg horizontal and apply ice to the affected leg

13. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed to perform which of the following?

a) changing the needle after drawing up the dose and before injection
b) preparing an air lock when drawing up the medication
c) using a Z-track method for injection
d) massaging the injection site after injection

14. A nursing student develops a plan of care for a client with paraplegia who has a risk for injury related to spasticity of the leg muscles. On reviewing the plan, the co-assigned nurse identifies which of the following as an incorrect intervention.

a) use of padded restraints to immobilize the limb
b) performing range of motion to the affected limbs
c) removing potentially harmful objects near the spastic limbs
d) use of prescribed muscle relaxants as needed

15. A registered nurse (RN) is observing a licensed practical nurse (LPN) preparing a client for treatment with a continuous passive motion (CPM) machine. Which observation by the RN would indicate that the LPN is performing an incorrect action?

a) places the client's knee in a slightly externally rotated position
b) keeps the client's knee at the hinged joint of the machine
c) assesses the client for pressure areas at the knee and the groin
d) checks the degree of extension and flexion and the speed of the CPM machine per the physician's orders

NCLEX for RN - Leadership and Management:

11) D
- It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung re-expansion. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection. The client is positioned in semi-Fowler’s to facilitate ease in breathing.

12) A
- Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and application of ice. Options B, C, and D are incorrect.

13) D
- The site should not be massaged after injection because massaging could cause staining of the skin. Proper technique for administering iron by the IM route includes changing the needle after drawing up the medication and before giving it. An air lock and Z-track technique both should be used. The medication should be given in the upper outer quadrant of the buttock, not in an exposed area such as the arms or thighs.

14) A
- Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. Removing potentially harmful objects is a good safety measure. Use of muscle relaxants also is indicated if the spasms cause discomfort to the client or pose a risk to the client’s safety. Use of limb restraints will not alleviate spasticity and could harm the client.

15) A
- In the use of a CPM machine, the leg should be kept in a neutral position and not rotated either internally or externally. The knee should be positioned at the hinge joint of the machine. The nurse should monitor for pressure areas at the knee and the groin and should follow the physician’s orders and institutional protocol regarding extension and flexion and speed of the CPM machine.

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