A client with a right hemopneumothorax has a chest tube connected to suction.
While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

Reinforce the connection of the chest tube to the container with tape.

Immediately clamp the chest tube with a plastic clamp.

Apply an occlusive dressing over the site of the chest tube.

Ensure that the chest tubing is neither kinked nor hanging low.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Reinforcing the connection of the chest tube to the container with tape is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the connection between the chest tube and the container is loose, but it does not address the immediate need of the client.
Choice B rationale
If a client with a chest tube becomes suddenly short of breath and anxious, the nurse should immediately clamp the chest tube with a plastic clamp. This is because the chest tube might have been disconnected from the water seal chamber, and clamping the tube can prevent air from entering the pleural space and causing a tension pneumothorax.
Choice C rationale

Applying an occlusive dressing over the site of the chest tube is not the immediate action to be taken when a client becomes suddenly short of breath and anxious. This action might be necessary if the chest tube is accidentally removed, but it does not address the immediate need of the client.
Choice D rationale
Ensuring that the chest tubing is neither kinked nor hanging low is an important part of the ongoing care for a client with a chest tube, but it is not the immediate action to be taken when a client becomes suddenly short of breath and anxious.

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Correct Answer is D

Explanation

Choice A rationale
While having a case management evaluation of the client’s home environment can provide valuable information and potential solutions for caregiving challenges, it does not directly address the caregiver’s immediate need for relief and support.

Choice B rationale

Hiring a private duty nurse could provide the caregiver with some time away from caregiving duties. However, this may not be a feasible option for many caregivers due to the cost associated with private nursing care.

Choice C rationale
Proposing that extended family could return to the area to help provide assistance assumes that such help is available and willing. This may not be the case for many caregivers.

Choice D rationale
Suggesting that social services be contacted to find a respite care facility for the client directly addresses the caregiver’s need for relief and support. Respite care provides temporary relief for primary caregivers, allowing them to rest and take care of their own needs. This can help to alleviate symptoms of caregiver burnout, such as poor sleep and frequent crying.

A. Schedule a client and family conference to review the plan of care. B. Explain that living wills cannot be followed by emergency personnel. C. Check the client’s arm for a “Do Not Resuscitate” (DNR) bracelet. D. Seek clarification of the type of advance directive the client has.

Correct Answer is D

Explanation

Choice D rationale
Seeking clarification of the type of advance directive the client has is the most appropriate response. A living will typically outlines a person’s wishes for end-of-life care, but it may not specifically address emergency situations like cardiac arrest.

Choice A rationale
Scheduling a client and family conference to review the plan of care may be helpful, but it is not the immediate priority. The nurse first needs to understand the client’s wishes as outlined in their advance directive.

Choice B rationale
Explaining that living wills cannot be followed by emergency personnel is not entirely accurate. While it’s true that emergency personnel initiating resuscitative measures may not have immediate access to a person’s living will, in a hospital setting, a person’s known wishes should be respected as much as possible.

Choice C rationale

Checking the client’s arm for a “Do Not Resuscitate” (DNR) bracelet is not the most appropriate response. While some people may choose to wear such a bracelet, not all do. Furthermore, a DNR order is just one type of advance directive, and it’s important to clarify what specific directives the client has in place.

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A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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A client with a right hemopneumothorax has a chest tube connected to suction.
While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?