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 D
Explanation
Choice A rationale
While it’s true that phantom limb pain can be a normal post-surgical sensation, simply reassuring the patient doesn’t address the pain they’re experiencing.
Choice B rationale
Guiding in moving the unaffected limb to override the sensation being experienced is not a recommended intervention for phantom limb pain. Phantom limb pain is a complex phenomenon that is not simply overridden by movement of other body parts.
Choice C rationale
Explaining that the sensations of tingling and pain are not real may invalidate the patient’s experience. Phantom limb pain is a real phenomenon experienced by many amputees. It’s not just a sensation; it’s a type of neuropathic pain that can be severe and debilitating.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is the best non-pharmacological intervention among the choices. Physical therapy, including mirror therapy and other desensitization techniques, can help manage phantom limb pain. The use of a prosthetic can help the patient regain function and mobility, which can also improve their overall well-being and potentially reduce the perception of phantom limb pain.
Correct Answer is B
Explanation
Choice A rationale
Osteoarthritis is a type of arthritis that occurs when the cartilage that cushions the ends of your bones in your joints gradually deteriorates. Osteoarthritis symptoms often develop slowly and worsen over time. They can include: Pain in the joint during or after use, or after periods of inactivity, Tenderness in the joint when you apply light pressure to or near it, Stiffness in the joint, that may be most noticeable when you wake up in the morning or after a period of inactivity, Loss of flexibility in the joint, Grating sensation or sound when you use the joint. But in this case, the client’s symptoms do not align with those of osteoarthritis.
Choice B rationale
Rheumatoid Arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels. Signs and symptoms of rheumatoid arthritis may include: Tender, warm, swollen joints, Joint stiffness that is usually worse in the mornings and after inactivity, Fatigue, fever and loss of appetite. The client’s symptoms align with those of Rheumatoid Arthritis.
Choice C rationale
Carpal Tunnel Syndrome is a condition that causes numbness, tingling and other symptoms in the hand and arm. Carpal tunnel syndrome is caused by a compressed nerve in the carpal tunnel, a narrow passageway on the palm side of your wrist. The anatomy of your wrist, health problems and possibly repetitive hand motions can contribute to carpal tunnel syndrome. But in this case, the client’s symptoms do not align with those of Carpal Tunnel Syndrome.
Choice D rationale
Gout is a common and complex form of arthritis that can affect anyone. It’s characterized by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe. An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable. But in this case, the client’s symptoms do not align with those of Gout.
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