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.'

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

A. Chart the reading at 91%, this is normal for a COPD patient. B. Place a non-rebreather on the patient with high ﬂow oxygen. C. Call the doctor if the patient is declining. D. Sit the patient up and have them breathe deep.

Correct Answer is D

Explanation

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Correct Answer is A

Explanation

RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Correct Answer is D

Explanation

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

The nurse is caring for a client who requires IV ﬂuids. which IV ﬂuid type would be considered a hypertonic solution?

A client with renal disease requires IV ﬂuids. It is important for the nurse to:

Your patient has a CMP drawn to determine their electrolytes. Only part of the values have resulted including the Na+ which is 121 mEq/l. What type of electrolyte imbalance is the patient having?

The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

The nurse is working in the intensive care unit and has just received lab results for her patients. Which of the following are considered electrolyte imbalances? (Select all That Apply)

Respiratory Therapy has an order to perform chest physiotherapy on your patient who has COPD. Your patient’s lung sounds are diminished, but free of secretions. What should the proper response be from the nurse to the respiratory therapist: