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
Hyponatremia is a condition where the sodium levels in the blood are abnormally low. It can cause confusion, seizures, and even coma in severe cases. The IV fluids hanging are 0.33% NaCI, which means they have a low sodium concentration, and may be contributing to the patient's hyponatremia.
Given that the patient is becoming increasingly confused, it is important to assess his mental status and monitor him closely to prevent harm. However, restraining the patient should not be the first course of action. Instead, the nurse should focus on identifying the underlying cause of the hyponatremia and taking appropriate steps to address it.
Therefore, the next step would be to get an order for additional lab work to assess the patient's electrolyte levels and identify the cause of the hyponatremia. This will help to guide further treatment and management decisions for the patient.
Correct Answer is ["A","B","E"]
Explanation
These are all electrolyte imbalances. Hyperkalaemia is an elevated level of potassium in the blood. Hypocalcaemia is a low level of calcium in the blood. Hyponatremia is a low level of sodium in the blood. Thrombocytopenia and anemia are not electrolyte imbalances. Thrombocytopenia is a low platelet count and anemia is a low red blood cell count or low hemoglobin levels.
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