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
Encouraging the client to participate in a team sport for one hour might be beneficial for the client’s physical health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice B rationale
Assisting the client in developing a list of daily affirmations can be a helpful strategy for improving self-esteem and promoting positive thinking, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice C rationale
Scheduling the client for a group session that focuses on self-esteem can be beneficial for the client’s mental health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice D rationale
Helping the client in identifying goals for the day can be a very effective intervention for a client with severe depression. Setting daily goals can provide the client with a sense of purpose and can help to motivate the client to engage in activities other than sitting and watching television.
Correct Answer is A
Explanation
Choice A rationale
A large, non-tender, hardened lymph node without overlying tissue inflammation could indicate malignancy. Lymph nodes may become enlarged or hard due to the presence of cancer cells.
Choice B rationale
While bacterial infections can cause lymph node enlargement, they typically also cause tenderness and overlying skin changes, such as redness or warmth.
Choice C rationale
Viral infections can cause generalized lymph node enlargement, but the nodes are usually tender and not hard.
Choice D rationale
Lymphangitis, or inflammation of the lymphatic channels, typically presents with red streaks on the skin, fever, and tenderness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.