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.

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Correct Answer is A

Explanation

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

A. Mg2 – 20 mEq/L B. Na+ - 123 mEq/L C. Ca2 – 10.0 mg/dl D. K+ - - 3.1 mEq/L

Correct Answer is D

Explanation

Atrial fibrillation is a common arrhythmia, and diuretics are often used in the management of patients with this condition to help control ﬂuid balance. However, diuretics can cause electrolyte imbalances, especially hypokalaemia (low potassium levels), which can lead to muscle cramps and other complications.

A Complete Metabolic Panel (CMP) is a blood test that measures various electrolytes, glucose, and other important components. Among the options given, the most likely lab value to be abnormal in Patient MK's case is a low level of potassium (K+), which is consistent with her symptoms and diuretic use. Option d, K+ -

1. mEq/L, is the correct option as it represents a low level of potassium, which is defined as a value less than 3.5 mEq/L.

Option a, Mg2 – 20 mEq/L, represents high magnesium levels, which are not typically associated with diuretic use or muscle cramps. Option b, Na+ - 123 mEq/L, represents low sodium levels, which are less likely to occur with diuretic use, and are typically associated with other conditions. Option c, Ca2 – 10.0 mg/dl, represents normal calcium levels and is not typically aﬀected by diuretic use.

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

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

Patient MK is admited with Atrial Fibrillation an irregular heart rhythm. She is also complaining of muscle cramps to her legs and that she started a new diuretic last week. What lab value are you most likely to find on her Complete Metabolic Panel?

Correct Answer is D

Explanation

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