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 A
Explanation
Choice B reason: Arranging diet schedule around three regular meals a day is not a sufficient point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus is a condition that affects the body's ability to produce or use insulin, a hormone that regulates blood glucose levels. Eating three regular meals a day may not be enough to control blood glucose levels and prevent complications such as hypoglycemia or hyperglycemia. The nurse should teach the client to follow a balanced diet that includes carbohydrates, proteins, fats, vitamins, minerals, and fiber, and to eat smaller portions more frequently throughout the day.
Choice C reason: Using garlic, herbs, and spices will improve the flavor of food is not a specific point for disease and symptom management for a client with type 2 diabetes mellitus. Garlic, herbs, and spices are natural ingredients that can enhance the taste and aroma of food, but they do not have a direct impact on blood glucose levels or diabetes complications. The nurse should teach the client to limit the intake of salt, sugar, and saturated fats, and to choose foods that are low in glycemic index and high in antioxidants.
Choice D reason: Inspecting feet every month for ingrown nails, cuts, and calluses is not a frequent enough point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the feet, leading to reduced sensation, poor circulation, infection, ulceration, and amputation. The nurse should teach the client to inspect feet every day for any signs of injury or infection, and to wash, dry, moisturize, and protect them properly. The nurse should also advise the client to wear comfortable shoes and socks, avoid walking barefoot, and seek medical attention for any foot problems.
Correct Answer is B
Explanation
Choice A: Recommending the use of support stockings to enhance venous return is not a priority intervention for the nurse, as this does not address the underlying cause of the peripheral edema, which is fluid overload due to inadequate dialysis. This is a distractor choice.
Choice B: Ensuring the client receives frequent small meals containing complete proteins is a priority intervention for the nurse, as this can help improve the client's nutritional status and increase their serum albumin level, which can reduce fluid leakage into the interstitial spaces and decrease edema. Therefore, this is the correct choice.
Choice C: Evaluating patency of the AV graft for resumption of hemodialysis is not a priority intervention for the nurse, as this is not feasible at this point since the AV graft is no longer available to use. This is another distractor choice.
Choice D: Instructing the client to continue to follow the prescribed rigid fluid restriction amounts is not a priority intervention for the nurse, as this does not address the root problem of inadequate dialysis and low serum albumin level, which are contributing to fluid overload and edema. This is another distractor choice.
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