Question: While a client's wife is visiting she observes the client's chest drainage system and begins to nervously question the nurse regarding the amount of bloody drainage in the system. What is the best response from the nurse?
1. "Your husband has been really sick; this must be a very difficult time. Let's sit down and talk about it."
2. "I have checked all of the equipment and it is working fine; you do not need to worry about it."
3. "The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding."
4. "The chest tube is draining the secretions from his chest; it is important for him to deep-breathe frequently."
Answer: 3.
Rationale: This is important information to explain to the client's wife regarding the bloody drainage in the chest tube collection system. After the nurse has explained the reason for the drainage, it would be appropriate to sit down and talk with the wife (option 1). Options 2 and 4 do not answer the question or address the wife's concern.
This week's NCLEX exam practice question is provided by:
Zerwekh: Illustrated Study Guide for the NCLEX-RN Exam, 7th edition, Chapter 15, Page 301 Question 7
Check out other great NCLEX exam resources from Elsevier!
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