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 D

The correct answer is Choice D.

Brief Introduction This scenario requires applying knowledge of chest tube dynamics and respiratory physiology during patient positioning. Sudden dyspnea in a patient with a hemopneumothorax indicates a potential obstruction in the drainage system, necessitating immediate troubleshooting of the tubing to ensure lung re-expansion and prevent tension pneumothorax or fluid accumulation.

Choice A rationale: Reinforcing the connection with tape is a preventive measure to maintain system integrity. However, it does not address the immediate cause of sudden acute respiratory distress following a position change, which is more likely related to a mechanical obstruction in the tubing rather than a connection failure.

Choice B rationale: Clamping a chest tube is generally contraindicated as it can rapidly lead to a tension pneumothorax by preventing the escape of air and fluid from the pleural space. This action would likely worsen the patient's anxiety and shortness of breath by increasing intrapleural pressure.

Choice C rationale: An occlusive dressing is only applied if the chest tube is accidentally dislodged from the insertion site. Since the scenario implies the tube is still in place but the patient became symptomatic during a turn, applying a dressing over an intact tube is an incorrect intervention.

Choice D rationale: Turning a patient can cause the chest tubing to kink or create dependent loops that trap fluid. This obstruction prevents the drainage of air and blood, leading to sudden respiratory distress. Ensuring the tubing is patent and straight is the immediate priority to restore proper pleural suction.

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Correct Answer is B

Explanation

Choice A rationale
While the patient’s currently prescribed medications are important information, they are not the most immediate concern in this situation. The healthcare provider will need this information, but it does not need to be the first piece of information provided.

Choice B rationale
The increasing confusion of the patient is the most immediate concern and should be communicated first. Confusion and disorientation can be signs of a serious condition such as a brain injury, especially following a fall. It is crucial to relay this information to the healthcare provider as soon as possible so that appropriate diagnostic tests can be ordered and treatment can be initiated.
Choice C rationale
The patient’s healthcare power of attorney is important information, especially if the patient’s condition worsens and they are unable to make decisions for themselves. However, this information does not need to be communicated first. The immediate concern is the patient’s medical condition.
Choice D rationale
The fall from a ladder is certainly important information as it provides context for the patient’s current condition. However, it does not need to be the first piece of information provided. The healthcare provider will likely infer that a fall has occurred based on the other information provided (e.g., confusion, potential loss of consciousness).

A. Lamb’s wool B. Sterile water C. Tape D. Suction canister E. Humidifier bottle F. Nasal cannula G. Flowmeter

Correct Answer is ["B","E","F","G"]

Explanation

Management of respiratory distress in a long-term smoker requires knowledge of oxygen delivery systems and airway humidification. The nurse must apply principles of respiratory therapy to select equipment that ensures precise flow regulation and moisture addition to prevent mucosal drying during supplemental oxygen administration.

Choice A rationale: Lamb’s wool is occasionally used to protect skin from pressure sores caused by medical tubing. However, it is not a standard or essential component for initiating oxygen therapy, as modern medical-grade foam dressings or specialized tubing protectors are more commonly utilized in clinical practice.

Choice B rationale: Sterile water is essential for the humidification process when oxygen flow rates exceed 4 liters per minute. It serves as the reservoir liquid in the humidifier bottle to ensure the inhaled gas is moist, preventing the drying of sensitive respiratory mucosa and secretions.

Choice C rationale: Tape is generally avoided when securing nasal cannulas because it can cause skin irritation or breakdown on the face. The cannula is designed to be secured using the integrated sliding bolo or by looping the flexible tubing comfortably behind the patient's ears.

Choice D rationale: A suction canister is used for removing secretions from the oropharynx or trachea. While it may be present at the bedside for safety, it is not a functional component of the oxygen delivery system itself, which focuses on gas inhalation rather than extraction.

Choice E rationale: A humidifier bottle is necessary to add water vapor to the dry oxygen gas provided by the wall source. Humidification is vital for patient comfort and to maintain the integrity of the mucociliary escalator, especially for patients with chronic lung irritation from smoking.

Choice F rationale: The nasal cannula is the primary interface for delivering low-to-medium concentrations of oxygen. It consists of two prongs that fit into the nares, allowing the patient to breathe supplemental oxygen while still being able to speak and consume fluids or meals.

Choice G rationale: A flowmeter is a critical device that attaches to the oxygen wall outlet to regulate the liters per minute delivered. It allows the nurse to accurately titrate the oxygen dose according to the healthcare provider's specific orders and the patient's oxygenation needs.

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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 B

Explanation

Correct Answer is ["B","E","F","G"]

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?