A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?
'It is unnecessary for you to go to the restroom at this time."
'I can assist you to the bathroom and back to bed."
'I cannot assist you at this time, please wait until I finish what I’m doing”.
'You cannot go to the bathroom.'
The Correct Answer is B
Chest tubes are inserted to drain fluid, blood, or air from the pleural space, which is the space between the lung and the chest wall. It is important to ensure that the chest tube is secured properly and the drainage system is functioning properly before the patient is ambulated. Additionally, the patient may experience discomfort or pain during ambulation, so it is important to assess and manage the patient's pain before and after ambulation.
Option A is not appropriate because it disregards the patient's need to use the restroom and may make the patient feel helpless or dependent.
Option c is not appropriate because it does not address the patient's request for assistance and may make the patient feel neglected or uncared for.
Option d is not appropriate because it is a directive statement that does not take into account the patient's autonomy or individual needs. It is important to involve the patient in the decision-making process and provide appropriate care based on their individual needs and preferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Daily weights provide a reliable and accurate measure of fluid balance in the body. An increase in weight can indicate fluid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most effective way to monitor for excess fluid volume in this situation.
Correct Answer is ["B","C","E"]
Explanation
Explanation: Central venous catheters are catheters that are inserted through a vein in the chest, neck, or groin and then threaded through to a large vein near the heart. These types of catheters are used for long- term treatment and monitoring of critically ill patients.
A midline catheter is a type of peripheral IV catheter that is longer and extends into the upper arm, but it does not reach a central vein and is not considered a central line. Therefore, option a. is incorrect.
A peripheral IV catheter is inserted into a peripheral vein (e.g., hand, arm), and it does not reach a central vein, making it a peripheral line. Therefore, option d. is incorrect.
A tunneled catheter is a type of central venous catheter that is inserted through a small incision in the chest and then tunneled under the skin to a central vein. It is typically used for long-term treatment and is less likely to become infected than a non-tunneled catheter. Therefore, option b. is correct.
A non-tunneled catheter is a type of central venous catheter that is inserted directly into a central vein in the chest, neck, or groin. It is typically used for short-term treatment and is more likely to become infected than a tunneled catheter. Therefore, option c. is correct.
A PICC line (peripherally inserted central catheter) is a type of central venous catheter that is inserted through a vein in the arm and then threaded through to a central vein near the heart. It is typically used for long-term treatment and is less invasive than other types of central lines. Therefore, option e. is correct.
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