A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?
Secure chest tube to the stretcher for transport.
Administer PRN pain medication prior to transport.
Mark the amount of chest drainage on the container.
Keep chest tube container below the site of insertion.
The Correct Answer is D
Choice A: Securing chest tube to the stretcher for transport is a good practice, but it is not the most important action. The chest tube should be secured to prevent accidental dislodgement or kinking, but it does not affect the function of the chest tube or the drainage system.
Choice B: Administering PRN pain medication prior to transport is a compassionate action, but it is not the most important action. The client may experience pain due to the chest tube, the intubation, or the underlying condition, but pain relief is not a priority over maintaining adequate ventilation and drainage.
Choice C: Marking the amount of chest drainage on the container is a useful action, but it is not the most important action. The amount of chest drainage should be recorded and reported to monitor the client's status and detect any complications, such as hemorrhage or infection, but it does not affect the immediate function of the chest tube or the drainage system.
Choice D: Keeping the chest tube container below the site of insertion is the most important action for the nurse to take. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: This is incorrect because instructing the client and family to reconsider end of life choices is disrespectful and insensitive. The nurse should respect the client's autonomy and preferences and support their decisions.
Choice B reason: This is correct because teaching the client how to use guided imagery is a helpful intervention for coping with feelings related to death and dying. Guided imagery is a relaxation technique that involves visualizing positive images and scenarios that can reduce stress, anxiety, and pain.
Choice C reason: This is correct because recording the client's desire to live is an important intervention for coping with feelings related to death and dying. The nurse should acknowledge and validate the client's emotions and help them express their hopes and fears.
Choice D reason: This is correct because encouraging family to visit frequently is a beneficial intervention for coping with feelings related to death and dying. The nurse should facilitate family involvement and communication and help the client maintain meaningful relationships.
Choice E reason: This is correct because encouraging family to bring the client old photographs is a useful intervention for coping with feelings related to death and dying. The nurse should assist the client in reminiscing and reviewing their life story and achievements.
Correct Answer is C
Explanation
Choice A reason: Feeding the infant every 4 hours is not a specific instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. However, feeding the infant frequently is important to promote hydration and elimination of bilirubin through urine and stool.
Choice B reason: Performing diaper changes under the light is not a recommended instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to turn off the light and cover the infant's eyes with protective goggles or patches during diaper changes to prevent eye damage or irritation.
Choice D reason: Covering with a receiving blanket is not an appropriate instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to keep the infant unclothed except for a diaper and eye protection during phototherapy to maximize skin exposure to the light and increase its effectiveness.
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