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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Histamine H2-receptor antagonists, also known as H2 blockers, are medications that help reduce the production of gastric acid. They achieve this by blocking H2 receptors in the parietal cells of the stomach, which are responsible for secreting hydrochloric acid (HCl)12. This reduction in acid secretion can help treat conditions such as peptic ulcers, gastroesophageal reflux disease (GERD), and Zollinger-Ellison syndrome, which are all conditions that can be exacerbated by excessive stomach acid.
Choice B rationale
While H2 blockers do help manage the symptoms of peptic ulcer disease, they do not directly destroy the microorganisms causing inflammation in the stomach. The primary cause of peptic ulcers is a bacterium called Helicobacter pylori, and the treatment for an H. pylori infection typically involves a combination of antibiotics and proton pump inhibitors, not H2 blockers.
Choice C rationale
H2 blockers do not neutralize hydrochloric acid (HCl) in the stomach. Instead, they work by reducing the amount of acid produced by the stomach. Antacids, not H2 blockers, are the class of drugs that work by neutralizing stomach acid.
Choice D rationale
H2 blockers do not inhibit the action of acetylcholine by blocking parasympathetic nerve endings. Anticholinergic medications are the ones that work by blocking the action of acetylcholine, a neurotransmitter that transmits signals in the nervous system.
Correct Answer is A
Explanation
Choice A rationale
The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.
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