Free NCLEX-RN Exam Braindumps (page: 134)

Page 134 of 431

The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

  1. Mother is concerned about her recovery.
  2. Mother calls infant by name.
  3. Mother lightly touches infant.
  4. Mother is concerned about her weight gain.

Answer(s): B

Explanation:

(A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase.



The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

  1. Mother is concerned about her recovery.
  2. Mother calls infant by name.
  3. Mother lightly touches infant.
  4. Mother is concerned about her weight gain.

Answer(s): B

Explanation:

(A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase.



A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:

  1. Prevent air from entering the pleural space
  2. Prevent fluid from entering the pleural space
  3. Provide a means to measure chest drainage
  4. Provide an indicator of respiratory effort

Answer(s): A

Explanation:

(A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal.



A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:

  1. Prevent air from entering the pleural space
  2. Prevent fluid from entering the pleural space
  3. Provide a means to measure chest drainage
  4. Provide an indicator of respiratory effort

Answer(s): A

Explanation:

(A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal.



Page 134 of 431



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